\ DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS for MEDICARE & MEDICAID SERVICES Region III/Division of Medicaid and Children's Health Operations .MAR 312009 John G. Folkemer Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Suite 525 Baltimore, MD 21201 Dear Mr. Folkemer: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 09-03. The amendment proposes to add Employed Individuals with Disabilities into the State plan under the eligibility groups authorized under section 1902( a)(1 O)(A)(ii)(XV) of the Social Security Act. The effective approval date for this amendment is October 1, 2008. If you have questions about this SPA, please contact Rosemary Feild at 215-861-4278. Sincerely, ~~~ Ted Gallagher Associate Regional Administrator Enclosure cc: Cheryl Camillo

Revision: Citation B. 1902(a)(1 O)(A) (ii)(XIII) of the Act 1902(a)(1 O)(A) (ii)(XV) of the Act 1902(a)(1 O)(A) (ii)(XVI) of the Act Staterrerritory: Maryland Groups Covered ATTACHMENT 2.2-A PAGE 23e Optional Groups Other Than the Medically Needy (Continued) [ ] 23. BBA Work Incentives Eligibility Group - Individuals with a disability whose net family income is below 250 percent of the Federal poverty level for a family of the size involved and who, except for earned income, meet all criteria for receiving benefits under the SSI program. See page 12c of Attachment 2.6-A. [X] 24. TWWIIA Basic Coverage Group - Individuals with a disability at least 16 but less than 65 years of age whose income and resources do not exceed a standard established by the State. See page 12d of Attachment 2.6-A. [] 25. TWWIIA Medical Improvement Group- Employed individuals at leas 16 but less than 65 years of age with a medically improved disability whose income and resources do not exceed a standard established by the State. See page 12h of Attachment 2.6A. NOTE: If the State elects cover this group, it MUST also cover the eligibility group described in No. 24 above. TN No. C2 q- 63 tMW{ Supersedes Approval Date: MAR 3 1 £.\ARI Effective Date: October 1 . 2008 TN No. New

Supplement 8a to Attachment 2.6-A Page 6 State Plan Under Title XIX of the Social Security Act State: Maryland LESS RESTRICTIVE METHODS OF TREATING INCOME UNDER SECTION 1902(r)(2) OF THE ACT For the SSI-related groups authorized under Section 1902(a)(lO)(A)(ii)(I), 1902(a)(lO)(A)(ii)(IV), 1902(a)(lO)(A)(ii)(XV), 1902(a)(lO)(C), 1902(a)(lO)(E)(i), 1902(a)(lO)(E)(iii), 1902(a)(lO)(E)(iv), and 1905(p) of the Social Security Act, the following more liberal methodologies apply: 1. All in-kind income is excluded. 2. Training allowances and expenses are excluded as countable income. 3. Educational work-study earnings, stipends, and reimbursement for out-of-pocket expenses are excluded as countable income. 4. Payments received under a crime victims compensation program are excluded as countable income. 5. Interest income accrued to bank accounts is excluded as countable income. · 6. All grants, loans, scholarships, fellowships, and training allowances for educational purposes and all educational expenses while in attendance are excluded as countable income. 7. All charitable contributions received are excluded as countable income. 8. Infrequent or irregular unearned income is excluded up to $200 per 6 months, and earned income is excluded up to $30 per quarter. 9. Room and/or board income received from a person living in the assistance unit's home is excluded. l 0. For consideration of rental property income and self-employment income, deduct 50% from the gross earnings as the cost to produce. For the AFDC-related groups authorized under Sections 1902(a)(l O)(A)(i)(III), l902(a)(l O)(A)(i)(IV), 1902(a)(l O)(A)(i)(VI), 1902(a)(l O)(A)(VII), 1902(a)(l O)(A)(ii)(I), 1902(a)(l O)(A)(ii)(VIII), 1902(a)(lO)(A)(ii)(IX), 1902(a)(10)(A)(ii)(XIV), and 1902(a)(10)(C) of the Social Security Act, the following more liberal methodology applies: l. Earned income of the child less than 18 years old is excluded. 2. All in-kind income is excluded. 3. All loans are excluded as countable income, regardless of whether the person is receiving money as the borrower or the lender. 4. Training allowances and expenses are excluded as countable income. 5. Educational work-study earnings, stipends, and reimbursement for out-of-pocket expenses are excluded as countable income. 6. Payments received under a crime victims' compensation program are excluded as countable income. 7. Interest income accrued to bank accounts is excluded. 8. All grants, loans, scholarships, fellowships and trainings allowances for educational purposes and all educational expenses .:re excluded as countable income. 9. All charitable contributions received are excluded as countable income. 10. Infrequent or irregular unearned income is excluded up to $200 per 6 months, and earned income is excluded up to $30 per quarter. 11. For consideration of room and/or board income, rental property income, and self-employment income, deduct 50% from the gross earnings as the cost to produce. 12. Disregard up to $200 per month per child in child care expenses for an assistance unit member who works 100 or more hours per month. Disregard up to $100 per month if the member works less than 100 hours per month. TNNo. D9-D3 Supercedes TN No. 04-20 MAR 3 12009.. . Approval Date·· Effective Date: October 1, 2008

Supplement 8b to Attachment 2.6A Page 5 State Plan Under Title XIX of the Social Security Act State: Maryland LESS RESTRICTIVE METHODS OF TREATING RESOURCES UNDER SECTION 1902(r)(2) OF THE ACT For the SSI-related groups authorized under Section 1902(a)(l O)(A)(ii)(!), 1902(a)(.l O){A)(ii)(IV), l902(a)( I O)(A)(ii)(V), 1902(a)(l O)(A)(ii)(XV), 1902(a)( I O)(C), 1902(a)(l O)(E)(i), 1902(a)(IO)(E)(iii), 1902(a)(lO)(E)(iv), and 1905(p) of the Social Security Act, the following more liberal methodologies apply: I . Any vehicle regardless of the value is excluded as a countable resource, except for airplanes, recreational vehicles, boats and their trailers, and antique cars which are not the assistance unit's primary vehicle. 2. Exclude as a countable resource all irrevocable or revocable burial or funeral plans which specify that a funeral home will receive all proceeds. Exclude other liquid resources designated for burial/funeral up to $1,500. 3. Exclude income-producing property as a countable resource if it annually produces income consistent with the fair market value. 4. Exclude household goods and personal effects, except for luxury items or valuable collections· (e.g .• antiques, stamp or coin collection, expensive jewelry other than wedding rings, fur coats). For the AFDC-related groups authorized under Se.ctions 1902(a)(l O)(A)(i)(III), 1902(a)( I O)(A)(i)(IV), 1902(a)( I O)(A)(i)(Vl), 1902(a)( I O)(A)(i)(VII), 1902(a)(l O)(A)(ii)(I), 1902(a)(IO)(A)(ii)(VII1), 1902(a)(IO)(A)(ii)(TX), 1902(a)(l0)(A)(ii)(XIV), and !902(a)(IO)(C), as further defined at Sections l905(a)(i). (ii), and (viii), of the Social Security Act, the following more liberal methodologies apply: I. All resources are disregarded. For the SSI-related groups authorized under 1902(a)( I O)(A)(ii)(XV) of the Social Security Act, the following more liberal methodologies apply: I. Exclude as a countable resource all retirement and pension plans except IRA accounts. 2. Exclude liquid resources up to $10,000. TNNo. ~3 hR ,, l ·-fll~UlO , Supersedes Approval d\AM 3 llJ'l:!l~. Effective Date: October 1, 2008 TN No. 08-05

Revision: Citation 1902(a)(1 O)(A)(ii) (XIII) of the Act Staterr erritory: Maryland Condition or Requirement ATTACHMENT 2.6-A Page 12c (i) Working Individuals With Disabilities -BBA In determining countable income and resources for working individuals with disabilities under BBA, the following methodologies are applied: The methodologies of the SSt program. The agency uses methodologies for treatment of income and resources more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 4 (income) and Supplement 5 (resources) to Attachment 2.6-A. The agency uses more liberal income and/or resource than the SSI program. More liberal methodologies are described in Supplement 8a to attachment 2.6-A. More liberal resource methodologies are described in Supplement 8b to Attachment 2.6-A. TN No. QCJ-03 Supersedes Approval MAR 3 1 200~ffective Date October 1, 2008 TN No. New

Revision: Citation 1902(a)(1 O)(A) (ii)(XV) of the Act TN No. 09-03 Supersedes TN No. New Revision: Statefferritory: Marvland Condition or Requirement ATTACHMENT 2.6-A Page 12d (ii) Working Individuals with Disabilities - Basic Coverage Group- TWWIIA In determining financial eligibility for working individuals with disabilities under this provision, The following standards and methodologies are applied: _ _ The agency does not apply any income or resource standard. NOTE: If the above option is chosen, no further eligibility-related options should be elected. _x_ The agency applies the following income and/ or resource standard(s): The total countable earned and unearned net income is 300% of FPL. Countable resources attributed to the assistance unit may not exceed $10,000. ~))oo~ ---=-- ~,;_ . _Effective Date: October 1. 2008 ATTACHMENT 2.6-A

Revision: Citation 1902(a)(1 O)(A) (ii)(XV) of the Act (cont.) State!T erritory: Maryland Condition or Requirement Income Methodologies ATTACHMENT 2.6-A Page 12e In determining whether an individual meets the income standard described above, the agency uses the following methodologies. The income methodologies of the SSI program. The agency uses methodologies for treatment of income that are more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 4 to Attachment 2.6- A. X The agency uses more liberal income methodologies than the SSI program. More liberal income methodologies are described in Supplement Sa to Attachment 2.6-A. TN No Q:i.=-0 3 U A R 3 2009 Super~edes Approval £1~ 1 Effective Date: October 1. 2008 TN No. New

Revision: Citation 1902(a)(10)(A) (ii)(XV) of the Act (cont.) Stateff erritory: Maryland Condition or Requirement Resource Methodologies ATTACHMENT 2.6-A Page 12f OMB No.: In determining whether the individual meets the resource standard described above, the agency uses the following methodologies. Unless one of the following items is checked, the agency, under the authority of 1902(r)(2) of the Act, disregards all funds held in retirement funds and accounts, including private retirement accounts such as IRAs and other individual accounts, and employer- sponsored retirement plans such as 401 (k) plans, Keogh plans, and employer pension plans. Any disregard involving retirement accounts is separately described in Supplement 8b to Attachment 2.6-A. The agency disregards funds held in employer- sponsored retirement plans, but not private retirement plans. X The agency disregards funds in retirement accounts in a manner other than those described above. The agency's disregards are specified in Supplement 8b to Attachment 2.6-A. TN No.09-03 Supersedes Approval ~~~ 3 1 200~ Effective Date: October 1. 2008 TN No. New

Revision: Citation 1902(a)(10)(A) (ii)(XV) of the Act (cont.) Stateff erritory: Maryland Condition or Requirement ATTACHMENT 2.6-A Page 12g · The agency does not disregard funds in retirement accounts. X The agency' uses resource methodologies in addition to any indicated above that are more liberal than those used by the SSI program. More liberal resource methodologies are described in Supplement 8b to Attachment 2.6-A. The agency uses the resource methodolgies of the SSI Program. The agericy uses methodologies for treatment of resources that are more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 5 to Attachment 2.6-A. TN No. ()Cf-03 Supersedes Approval ~ 3 1·2009 Effective Date: October 1. 2008 TN No. New

Revision: Citation 1902(a)(1 O)(A) (ii)(XVI) of the Act Stateff erritory: Maryland Condition or Requirement ATTACHMENT 2.6-A Page 12h (ii) Working Individuals with Disabilities - Employed Medically Improved Individuals - TWWIIA In determining financial eligibility for employed medically improved individuals under this provision, the following standards and methodologies are applied: __ The agency does not apply any income or resource standard. NOTE: If the above option is chosen, no further eligibility-related options should be elected. The agency applies the following income and/ or resource standard(s): TN No. {)q-03 Supersedes Approval MAR 3 1 2009 Effective Date: October 1. 2008 TN No. New

Revision: Citation 1902(a)(10)(A) (ii)(XVI) of the Act (cont.) StatefT erritory: Maryland Condition or Requirement Income Methodologies ATTACHMENT 2.6-A Page 12i In determining whether an individual meets the income standard described above, the agency uses the following methodologies. The income methodologies of the SSI program. The agency uses methodologies for treatment of income that are more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 4 to Attachment 2.6-A. The agency uses more liberal income methodologies than the SSI program. More liberal income methodologies are described in Supplement 8a to Attachment 2.6-A. TN No . .Q!J:03 Supersedes Approval D . R 3 1 2009 Effective Date: October 1. 2008 TN No. New

Revision: Citation 1902(a)(1 O)(A) (ii)(XVI) of the Act (cont.) StatefT erritory: Maryland Condition or Requirement Resource Methodologies ATTACHMENT 2.6-A Page 12j In determining whether the individual meets the resource standard described above, the agency uses the following methodologies. Unless one of the following items are checked, the agency, under the authority of 1902(r)(2) of the Act, disregards all funds held in retirement funds and accounts, including private retirement accounts such as IRAs and other individual accounts, and employer- sponsored retirement plans such as 401 (k) plans, Keogh plans, and employer pension plans. Any disregard involving retirement accounts is separately described in Supplement 8b to Attachment 2.6-A. The agency disregards funds held in employer- sponsored retirement plans, but not private retirement plans. The agency disregards funds in retirement accounts in a manner other than those described above. The agency's disregards are specified in Supplement 8b to Attachment 2.6-A. TN No. Q!/..::03 Supersedes Approval M4~ 3 1 20()9" Effective Date: October 1 , 2008 TN No. New

Revision: Citation 1902(a)( 1 O)(A) (ii)(XVI) of the Act (cont.) Staterr erritory: Maryland Condition or Requirement ATTACHMENT 2.6-A Page 12k The agency does not disregard funds in retirement accounts. The agency uses resource methodologies in addition to any indicated above that are more liberal than those used by the SSI program. More liberal resource methodologies are described in Supplement 8b to Attachment 2.6-A. The agency uses the resource methodolgies of the SSI Program. The agency uses methodologies for treatment of resources that are more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 5 to Attachment 2.6-A. TN No. QE..:-03 Supersedes Approval ~a~~ 3 1200fl Effective Date: October 1. 2008 TN No. New

Revision: Citation 1902(a)(1 O)(A) (ii)(XVI) and 1905(v)(2) of the Act. Stateff erritory: Maryland . Condition or Requirement ATTACHMENT 2.6-A Page 121 Definition of Employed - Employed Medically Improved Individuals- TVVWIIA The agency uses the statutory definition of "employed", i.e .. earning at least the minimum wage, and working at least 40 hours per month. The agency uses an alternative definition of "employed" that provides for substantial and reasonable threshold criteria for hours of work, wages, or other measures. The agency's threshold criteria is described below: TN No. Q3.::.. D 3 Supersedes Approva~ 3 l 2009 Effective Date: October 1, 2008 TN No. New

Revision :. Citation 1902(a)(1 O)(A)(ii)(XIII) (XV), (XVI), and 1916(g) of the Act StatefT erritory: Maryland Condition or Requirement ATTACHMENT 2.6-A Page 12m Payment of Premiums or Other Cost Sharing Charges For individuals eligible under the BBA eligibility group described in No. 23 on page 23e of Attachment 2.2-A: The agency requires payment of premiums or other cost-sharing charges on a sliding scale based on income. The premiums or other cost-sharing charges, and how they are applied are described below: TN No. oq-()3 Supersedes Approvatl'AB · 3 1 2009 Effective Date. October 1. 2008 TN No. New

Revision: Citation 1902(a)( 1 O)(A)(ii) (XIII), (XV), and 1916(g) of the Act (cont.) Staterrerritory: Maryland Condition or Requirement ATTACHMENT 2.6-A Page 12n For individuals eligible under the Basic Coverage Group described in No. 24 on page 23e of Attachment 2.2-A: NOTE: Regardless of the option selected below, the agency MUST require that individuals whose annual adjusted gross income, as defined under IRS statute, exceeds $75,000 pay 100 percent of premiums. X The agency requires individuals to pay premiums or other cost-sharing charges on a sliding scale based on income. For individuals with net annual income below 450 percent of the Federal poverty level for a family of the size involved, the amount of premiums cannot exceed 7.5 percent of the individual's income. The premiums or other cost-sharing charges, and how they are applied are described on page 12o. TN No. oq-03 R 'llooo Supersedes Approval oaMA 3 1 LJ ·~ Effective Date: October 1 I 2008 TN No. New

. . Revision: Citation Sections 1902(a)(1 O)(A) (ii)(XV), and 1916(g) of the Act (cont.) TN No. 69~0 3 State/Territory: Maryland Condition or Requirement ATTACHMENT 2.6-A Page 12o Premiums and Other Cost-Sharing Charges For the Basic Coverage Group, the agency's premium and other cost-sharing charges, and how they are applied, are described below. There are four income tiers for Employed Individuals with Disabilities. There is no premium amount for income which is at or below 1 00% of FPL; a monthly premium of $25 applied to income above 1 00% FPL but at or below 200%; a monthly premium of $40 applied to income above 200% FPL but at or below 250% FPL ; and a monthly premium of $55 for income above 250% but at or below 300% FPL. Supersedes Approval Om~ r: ·:t ·9 ~' Effective Date: October 1. 2008 TN No. New fYbt- ,.. t )l ::m::

\ \ ~ DEPARTMENT OF HEALTH AND HV~ 1AN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER: 09-03 2. STATE Maryland FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGlONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE 1 SOCIAL SECURITY ACT (MEDICA1D) 4. PROPOSED EFFECTTVE DATE October I, 2008 ----L.--- 5. TYPE OF PLAN MATERIAL (Check One): [' NEW STATE PLAN I ' AMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Section 1902(a) ofthe Social Security Act a. FFY 2009 $ Uflknewo fc:J. • ft,s MlLuoAJ RP Section 1902 (r)(2) ofthe Social Security Act b. FFY 2010 ~ Unknewn t '3. as- M IC<..t o,U rtt=- Section 1916(g) ofthe Social Security Act 8. PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): Attachment 2.2-A, Page 23e. New Attachment 2.6-A Pages 12c thru 12o New Supplement 8a to Attachment 2.6-A. Page 6 Supplement Sa to Attachment 2.6-A, Page 6 Su lement 8b to Attachment 2.6-A, Pa e 5 Su lement 8b to Attachment 2.6-A, Pa e 5 10. SUBJECT OF AMENDMENT: To add Employed Individuals with Disabilities into the State plan under the eligibility groups authorized under sections 1902(a)(IO)(A)(ii)(XV) of the Social Security Act. 1\. GOVERNOR'S REVIEW (Check One): 12. 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL AGENCY OFFICIAL: X OTHER, AS SPECIFIED: The Secretary of the Department of Health and Mental Hygiene 16. RETURN TO: Susan Tucker ---,--,:--:::,..r----1'""'-'=-t'-"--=----,--------------; Executive Director 13 · Office of Health Services --:---:::==:-::-----=---=------=-.,--------------l Department of Health & Mental Hygiene 201 W Preston St, I st floor ------t Baltimore MD 21201 .. FORM CMS-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 7,7 b 150 S. Independence Mall West

Suite 216, The Public Ledger Building CENTERS for MEDICARE & MEDICAID SERVICES

Philadelphia, Pennsylvania 19106-3499

Region III/Division of Medicaid and Children’s Health Operations

4 March 2010

John G. Folkemer

Deputy Secretary

Health Care Financing

MD Department of Health and Mental Hygiene 201 West Preston Street, Suite 525

Baltimore, MD 21201

Dear Mr. Folkemer:

Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 09-07. The amendment provides coverage to qualified alien children with incomes up to 300% of the Federal Poverty Level (FPL) and qualified alien pregnant women with incomes up to 250% FPL, in accordance with Section 214 of CHIPRA.

The effective approval date for this amendment is April 1, 2009. The signed CMS-179 form and the approved State Plan pages are enclosed. If you have questions about this SPA, please contact Rosemary Feild at 215-861-4278.

Sincerely,

/s/

Ted Gallagher

Associate Regional Administrator

Enclosure

ce: Lorie Mayorga Lisa Fassett

FEDERAL REGULATION CITATIONS: SPA 09-07 ___ Attachment 2.2A 42 CFR 435.10 _X_ Attachment 2.6A 42 CFR Part 435, Section 435.10 and Subparts G&H AT-78-90, AT-80-6, AT-80-34, 1902(I) and (n) of the Act, P.L. 99-509 (Secs. 9401 and 9402), 1902 (I) and (n) and 1920 of the Act, P.L. 99-509 (Secs. 9401, 9402, and 9407) _ Attachment 3.1A Part 400, Subpart B and 1902(e)(5), 1905(a)(18) through (20), and 1920 of the Act, P.L. 99-272 (Sections 9501, 9505 and 9526) and 1902(a), 1902(a47), 1902 (e)(7) through (9), and 1920 of the Act, P.L. 99-509 (Sections 9401(d), 9403, 9406 through 9408) and P.L. 99-514 (Section 1985(c)(3)) Attachment 3.1B 42 CFR Part 440, Subpart B, 42 CFR 441.15, AT-78-90, AT-80-34 ____ Attachment 3.1C 42 CFR 431.53, AT-78-90 Attachment 3.1F 1905(a)(24) and 1930 of the Act, P.L. 101-508 (Section 4712 OBRA 90) Attachment 4.18A 447.51 through 447.58 Attachment 4.18C 447.51 through 447.58 __. Attachment 4.18-F — 447.50-447.59

Attachment 4.19 A&B (a) 42 CFR 447.252, 46 FR 44964, 48 FR 56046, 50 FR 23009, 1902(e)(7) of the Act, P.L. 99-509 (Section 9401(d))

(b) 42 CFR 447.201, 42 CFR 447.302, AT-78-90, AT-80-34, 1903(a)(1) and (n) and 1920 of the Act, P.L. 99-509 (Section 9403, 9406 and 9407), 52 FR 28648

Attachment 4.16 42 CFR 431.615(c) AT-78-90

___ Attachment 4.19D — (d) 42 CFR 447,252, 47 FR 47964, 48 FR 56046, 42 CFR 447.280, 47 FR 31518, 52 FR 28141

___ Attachment 4.22A —_(a) 433.137( a), 50 FR 46652, 55 FR 1423

Attachment 4.22B (b) 433.138(f), 52 FR 5967, 433.138(g)(1)(ii) and (2)(ii), 52 FR 5967, 433.133(g)(3)(i) and (iii), 52 FR 5967, 433.138(h)\(4)(i) through (iii), 52 FR 5967

Attachment 4.22C Section 1906 of the Act

____ Attachment 4.26 1927(g) 42 CFR 456.700, 1927(g)(1)(A), 1927(g)(1)(a) 42 CFR 456.705(b) and 456.709(b), 1927(g)(1 (B) 42 CFR 456.703(d) and (f), 1927(g)(1)(D) 42 CFR 456.703(b), 1927(g)(2)(A) 42 CFR 456.705(b), 1927(g)(2A){i) 42 CFR 456.705(b), 1927(g2)(A)(i) 42 CFR 456.705(b), (1)-(7), 1927(g)(2)(A)(ii) 42 CFR 456.705(c) and (d), 1927(gX2)(B) 42 CFR 456.709%a), 1927(g)(2(C) 42 CFR 456.709(b), 1927(g)(2D) 42 CFR 456.711, 1927 (gX3)(A) 42 CFR 456.716(a), 1927 (g)(3)(B) 42 CFR 456.716 (A) and (B), 1927(g)(3)(C) 42 CFR456.716 (d) 1927(g3(C) 42 CFR 456.711 (a)-(d), 1927 (g{3)(D) 42 CFR 456.712 (A) and (B), 1927(b)(1) 42 CFR 456.722, 1927(g}(2)(A)i) 42 CFR 456.705(b), 1927(j(2) 42 CFR 456.703(c)

Attachment 4.32A (a) 435.940 through 435.960, 52 FR 5967 Attachment 4.33A (a) 1902(a)(48) of the Act, P.L. 99-570 (Section 11005), P.L. 100-93 (Section 6(a)(3)) Attachment 4.35A (a) 1919(b)(1) and (2) of the Act, P.L. 100-103 (Section 4212(a))

Attachment 4.35B (b) Same as above

Revision: CMS-PM- ATTACHMENT 2.6-A Page 2 OMB No.:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Maryland

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement 1905(p) of the Act b. For the medically needy, meets the non- financial eligibility conditions of 42 CFR Part 435.

1905 (s) of the Act c. For financially eligible qualified Medicare beneficiaries covered under section 1902(a{ 10)(E)(i)of the Act, meets the non-financial criteria of section 1905(p) of the Act.

d. For financially eligible qualified disabled and working individuals covered under section 1902(a)(10(EXii) of the Act, meets the non-financial criteria of section 1905(s).

42 CFR 435.406 3. Is residing in the United States, and--

a. Is a citizen or national of the United States;

b. Is a qualified alien (QA) as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) as amended, and the QA’s eligibility is required by section 402(b) of PRWORA as amended, and is not prohibited by section 403 of PRWORA as amended;

c. Is a qualified alien subject to the 5-year bar as described in section 403 of PRWORA, so that eligibility is limited to treatment of an emergency medical condition as defined in section 401 of PRWORA;

d. Is a non-qualified alien, so that eligibility is limited to treatment of an emergency medical condition as defined in section 401 of PRWORA;

e. Is a qualified alien (QA) whose eligibility is authorized under section 402(b) of PRWORA as amended, and is not prohibited by section 403 of PRWORA as amended. x State covers all authorized QAs. State does not cover authorized QAs.

f. State elects CHIPRA option to provide full Medicaid coverage to otherwise eligible aliens lawfully residing in the United States; consisting of the following:

() “Qualified aliens” otherwise subject to the 5-year waiting period per section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996;

(2) Citizens of a Compact of Free Association State (i.e., Federated States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau) who have been admitted to the United States

TN No: 09-07 Approval Date MAR A OS Bpfective Date: APRIL | AO00F. Supersedes TN No, 92-11

Revision: CMS-PM- ATTACHMENT 2.6-A Page 3 OMB No.: STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Maryland ELIGIBILITY CONDITIONS AND REQUIREMENTS Citation(s) Condition or Requirement

G3)

(4)

(U.S.) as non-immigrants and are permitted by the Department of Homeland Security to reside permanently or indefinitely in the U.S.;

Individuals described in 8 CFR 103.12(a)(4) who do not have a permanent residence in the country of their nationality and are in statuses that permit them to remain in the U.S. for an indefinite period of time pending adjustment of status. These individuals include:

(a) Individuals currently in temporary resident status as Amnesty beneficiaries pursuant to section 210 or 245A of the Immigration and Nationality Act (INA);

(b) Individuals currently under Temporary Protected Status pursuant to section 244 of the INA;

(c) Family Unity beneficiaries pursuant to section 301 of Public Law 101-649 as amended, as well as pursuant to section 1504 of Pub. L. 106-554;

(d) Individuals currently under Deferred Enforced Departure pursuant to a decision made by the President; and

(e) Individuals who are the spouse or child of a U.S. citizen whose visa petition has been approved and who has a pending application for adjustment of status; and

Individuals in non-immigrant classifications under the INA who are permitted to remain

in the U.S. for an indefinite period, including the following who are specified in section

101(a)(15) of the INA:

¢ Parents or children of individuals with special immigrant status under section 101(a)(27) of

the INA as permitted under section 101(a)(15)(N) of the INA;

© Fiancées of a citizen as permitted under section 101(a)(15)(K) of the INA; © Religious workers under section 101(a)(15)(R); ¢ Individuals assisting the Department of Justice in a criminal investigation as permitted

under section 101(a)(15)(U) of the INA; Battered aliens; and

Individuals with a petition pending for 3 years or more as permitted under section 101(a)(15)(V) of the INA.

4 Elected for pregnant women. x Elected for children under age 21.

2. X ~The State provides assurance that for individuals whom it enrolls in Medicaid under the CHIPRA section 214 option that it has verified, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State niust first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act. .

&

TN No: _09-07 Approval paMAR SUL Effective Date: PRit | 4009

Supersedes

TN No. 92-11

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF |. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 09-07 Maryland

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

TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES April 1, 2009 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One):

__ | NEW STATE PLAN {! AMENDMENT TO BE CONSIDERED AS NEW PLAN X_ AMENDMENT __ COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) __ 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Section 1902 of the Social Security Act a FFY 2009 $74 milion Section 2101 of the Social Security Act b. FFY 2010 $ 9 million 8. PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (if Applicable): Pages 2, 3, Attachment 2.6-A Pages 2, 3, Attachment 2.6-A

10. SUBJECT OF AMENDMENT: To provide for Medicaid/CHIP coverage to 1) qualified alien children below the 5-year bar with incomes up to 300% FPL and 2) qualified alien pregnant women below the 5-year bar with incomes up to 250% FPL, through a federally-supported program. This coverage is provided currently through a state-funded program referred to as “State-funded Medical Assistance for Ineligible Aliens.” 11, GOVERNOR’S REVIEW (Check One):

[_] GOVERNOR’S OFFICE REPORTED NO COMMENT X OTHER, AS SPECIFIED: The Secretary of the

(] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Department of Health and Mental Hygiene

(] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

oo) 12. ear den AGEACX OFFICIAL: 16. RETURN TO: { ( bh Cua Susan Tucker 13. TYPED NSME: John M. Colmers Executive Director ~ Office of Health Services 14. TITLE: Secretary, Department of Health & Mental | Department of Health & Mental Hygiene Hygiene 201 W Preston St, 1" floor 15. DATE SUBMITTED: 6/2-4/0 g Baltimore MD 21201 ‘ FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: ¢ / 29 oF 18. DATE APPROVED: MAR 4 20i6 g PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE of APPROVED MATERIAL: 20. SIGNATURE TONAL OFFICIAL: PRL tf. ACO — 2 | smote 21. TYPED NAME: ; 22. TITLE: _ yi TED CALCAGH OY. ASSOCIATE x EGE ron Ag itins SPRATA 23. REMARKS:

FORM CMS-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS !rJr MEDICARE & MEDICAID SEIMCES Region III/Division of Medicaid and Children's Health Operations SEP 14 20101 John G. Folkemer Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Suite 525 Baltimore, MD 21201 Dear Mr. Folkemer: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 10-08. This SPA extends Medicaid to independent foster care adolescents, in accordance with State legislation, to provide for individuals who were in foster care under the responsibility of the State on their 18 1h birthday and have not reached the age of 21. The effective date for this amendment is April 1, 20 I 0. The signed CMS Form 179 and the approved State Plan pages are enclosed. If you have questions about this SPA, please contact Rosemary Feild at 215-861-4278. Enclosure cc: Lorie Mayorga Lisa Fassett Sincerely, --iRd ~a_ k Ted Gallagher ~ Associate Regional Administrator

Revision: CMS-PM­ ATTACHMENT 2.2-A Page 23f State: Maryland Citation Groups Covered B. Optional Groups Other Than the Medically Needy (Continued) Sections 477, X 26. Independent Foster Care Adolescents. 1902(a)(10)(A)(ii)(XVII), An individual who is younger than age 21, who on the and 1905(w) ofthe Act individual's 18th birthday was in foster care under the responsibility of a State, who meets the targeting criteria in a.) below, and whose income and resources do not exceed the level( s), if any, established in b.) below. a. Individuals who meet the following criteria: 1) Are under the age of: X 21 20 19 2) Are: X All such individuals. Individuals for whom foster care maintenance payments or independent living services were furnished under a program funded under title IV-E before the date the individual turned 18 years old. Other reasonable classifications: b. Financial requirements J) Income test: X There is no income test. The income test is: 2) Resource test: X There is no resource test. The resource test is: Note: Ifthere is an income or resource test, the standards and methodologies may not be more restrictive than those for the State's section 1931 population, as specified in Supplement 12 of Attachment 2.6-A. TN No. J..!2-.:- 0 $? Approval Date: SEP 1.. 4 2010 Effective Date: April 1, 2010 Supersedes TN No. New

SUPPLEMENT 8a TO ATTACHMENT 2.6·A PageS State Plan Under Title XIX of the Social Security Act State: Maryland LESS RESTRICTIVE METHODS OF TREATING INCOME UNDER SECTION 1902(r)(2) OF THE ACT X For "independent foster care adolescents" (as defined in ~ 1905(w)(1) of the Social Security Act) who do not qualify for payments under Title IV -E ofthe Social Security Act, the agency does not consider income in determining eligibility, in accordance with the option under §1902( a)( 1 O)(A)(ii){XVII) of the Social Security Act. X For individuals under age 21 (as defined in section 1902(a)(lO)(A)(ii)(VIII) of the Social Security Act) who are under State adoption assistance agreements, have special needs for medical or rehabilitative care that made the child difficult to place, and do not qualify for payments under Title IV -E of the Social Security Act, the agency does not consider income in determining eligibility. TN No. 10-08 Approval Date: SEP 1 4 2010 Effective Date: April 1, 2010 Supercedes TN No. 03-09

SUPPLEMENT 8b TO ATTACHMENT 2.6-A Page 4 State Plan Under Title XIX of the Social Security Act State: Maryland LESS RESTRICTIVE METHODS OF TREATING RESOURCES UNDER SECTION 1902(r)(2) OF THE ACT X For "independent foster care adolescents" (as defined in ~ 1905(w){1) of the Social Security Act) who do not qualify for payments under Title IV-E ofthe Social Security Act, the agency does not consider resources in determining eligibility, in accordance with the option under §1902(a)(l0)(A)(ii)(XVII) of the Social Security Act. X For individuals under age 21 (as defined in section 1902(a)(lO)(A)(ii)(VIII) ofthe Social Security Act) who are under State adoption assistance agreements, have special needs for medical or rehabilitative care that made the child difficult to place, and do not qualify for payments under Title IV-E of the Social Security Act, the agency does not consider resources in determining eligibility. o SEP 14 2010 TN NoJD -() () Approval Date: _"'______ Effective Date: April 1, 20 lO Supercedes TN No. 03-9

DEPARTMENT OF HEAL fH A.'v'D Hul-fAN SERVICES C['NT[RS FOR IvIEDiCARE &;;...;rv-:cIE=~D",-IC~:A=ID;.....;S=·E,,-,-RV-,I.=CES="_~______ TRANSMITTAL AND ~OTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVlCES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAlD SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 3. PROORAM IDENTIFICATION: TITLE XJX OF THE SOCIAL SECURITY ACT (MEDICAID) MEDICAID 4. PROPOSED EFFECTIVE DATE April 1, 2010 NEW STAlE PLA:'\! AMENDMENT TO BE CONS1DERED AS NEW PLAN A AMENDMENT --~~~~~~==~~==~~~~~~~~~~~~~~~--~--~~~~---~---------­ COMPLETE BLOCKS 6 THRU 10 IF TIllS IS AN AMENDMENT Se (11'ate Transmittal or Mch amendment) --trFEDERAL STATLTE''REGULATION CITATION: 7. FEDERt\L BUDGET IMPACT: Section 1902~rK2) of the Social Security Act a. FFY 2010 $ 85,000 S~ction 1905~the Social Security Act b. FFY.fQll $100,000 "iCPAGE NUMBER OF THE PLAN SECTION OR 1 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHME~ 1111.1-~ I OR ATTACHMENT r/fApplicahle): Page 23[, S~~enf"2.2-A (new page) NEW Page 5, Supplement 8a to Attachment 2.6-A Page 5, Supplement 8a to Attaclunent 2.6-A trill 03-tlV flftiE 4-, ~vfPLE:I<I::.?J'f gil '1-0 If7T11C11JiOt'T ,;;(-,",-11 •f/1f(;.E 'f. SvP(,(£IIfYJ/ g b )'O/)7T7/-eJfHtW/,?;(I/'tHT).I(J3"t!9) SUBJECT OF Al\1ENDMENT: To provide for comprehensive medical assistance benefits to independent foster care adolescents who are not othernise eligible, in accordance with the passage of state legislation. To provide for individuals who: 1) Were in foster care under the responsibility of the State on their eighteenth birthday; 2) Have ,___, not reached the age of21t-&ftd 3) Have l;uH,J,s@1ieiG i8eome that Goes Ret I~eed 300°4 efthe FPL. II. GOVERNOR'S REVIEW (Ch£!CK Onel: o GOVERNOR'S OFFICE REPORTED NO COMMENT X OTHER, AS SPECIFIED: The Secretary of the o COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Department of Health and Mental Hygiene o NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITIAL 16, RETIJRJ.""l TO: [. Susan Tucker -13-.+~:.::::.:=t---=-~~~~=-:-------------------i Executive Director ----"oo..c----:--------:----------:------,---.....,------; 0 mce of Health Services I·t TITLE: Secretary, Department of Health & Mental Department of Health & Mental Hygiene Hygiene 15. DATE SUBMITTED: vt/11/E .;(;;;" dJ.tJ 10 1201 W Preston St. 1 ~ floor . Baltimore MD 21201 FOR REGIONAL OFFICE liSE ONLY "7.DATERECEIVED: .::TVAic d2;;J.., ;;Ld/~ !t8.DATEAPPROVED: SE'P 142010' 23. REMARKS: CI/,6Y2"f77tJl/J~ l'etJ 11A1!J INk Clt,1/116't.=$ 'to ~ s: H ~ ) Si'/ q 4-A/LJ SLJI$Jc:r.!7"'c}'c /J,q6.-#J)}fl.~ tv6Y<..e /f.1- 0 F / ~ ~t(1)41//cr lUI TJ:/ <;;:'7Jf-;r;.:­ FORM CMS-179 107-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS lor MEDICARE & MEDKA/0 SEIMCES Region IIJ/Division of Medicaid and Children's Health Operations SEP 2 8 2010 John G. Folkemer Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Suite 525 Baltimore, MD 21201 Dear Mr. Folkemer: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 10-09. This SPA implements Express Lane Eligibility for children, in which the Maryland Comptroller will identify through annual State income tax returns those families who are below 300 percent of the Federal Poverty Level and who indicate that their children do not have health insurance coverage. These families will initially receive simplified applications and eventually will have eligibility for Medicaid and the Maryland Children's Health Program determined through this process. We understand from our review of this SPA that using only a finding of residency is a first step towards implementing a more robust Express Lane Eligibility process that will eventually utilize a more efficient method of enrollment using income findings through an Interagency Agreement with the Maryland Comptroller. We will continue to work with your staff to ensure that Maryland can realize a more efficient Express Lane Eligibility process that can provide health care to its eligible but not enrolled children. The effective date for this amendment is April1 , 2010. The signed CMS Form 179 and the approved State Plan pages are enclosed. If you have questions about this SPA, please contact Rosemary Feild at 215-861-4278. Enclosure cc: Tricia Roddy Debbie Ruppert Lisa Fassett Sincerely, -I~~~ Ted Gallagher Associate Regional Administrator

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: rvlarvlaud Medical Assistance Program Citation(s) 1902(e)( 13) of the Act Page lib SECTION 2- COVERAGE AND ELIGIBILITY 2.1 Application, Determination of Eligibility and Furnishing Medicaid (Continued) ] (e) Express Lane Option. The Medicaid State agency elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of Medicaid eligibility. The Medicaid State agency agrees to meet all of the Federal statutory and regulatory requirements for this option. This author.ity may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (I) The Express Lane option is applied to: ~ Initial determinations [ I Both 0 Redeterminations (2) A child is defined as younger than age: Kl 19 [ ] 20 0 21 (3) The following public agencies are approved by the Medicaid State agency as Express Lane agencies: The Expr .:~s Lane ,\gl'ncy will be thl' Maryland Of'lic<' ofthL' Comptroller. Tht:. State will usc mronnation frum income tax rcn,rds. TN No.: I o- 0 Cf Approval ~p 9 R ?010" Effective Date t)/.1/ tJI/ tf(O tO Supersedes TN No.: t.le"W · ·

Citation(s) STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Maryland Medical Assistance Program Page lie SECTION 2- COVERAGE AND ELIGIBILITY 2.1 Application, Determination of Eligibility and Furnishing Medicaid (Continued) (4) The following component/components of Medicaid eligibility are determined under the Express Lane option. Also, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between Medicaid eligibility determinations for such children and the determination under the Express Lane option. The Stale· will u'c the iv!:JrvlanJ la .xpa~.-: 1 Jilin~ In ,·,-rifl '" n <' OIIlJ'<I IIc'll l~ ,,f appli.:::mt,· cligthility. Jnili:Jlly. lax infor- malll)ll ''iII he: U\t:u I<• ,.,., i fy r c~id..:ncy. Th.: State 11 ill ll'l' inftum;Hion fl(llll 1 he OrJi.:c of th,· Comptroller 10 idt:nti fy l arn l! i,·~ with <.kpcmknt <.:hilJr,·n 11-ilh inct l ll ll'~ hc l''" JllO per l'<'Tll 111' the hxkr.1l pnvcrtv lcvd The inf0rmati0n will h..· m,·J lu l:rrgcl \lrc•amlincu appltGIIItlll '- '"the,,· f:unol ic ~ The St:JIC' ahn h:J, lq:i,Jati<-r aulhotill In ll'l' oth,·t ClllllJlllllt:Tit' olth<' Ia ~ ltlrn ~ .111J . upPn lunlrn c<:Jiual inn a11J plan- ntng. will ll'<' the ill<'lllll<' inftJIIll:rtinn for apphc·anl' (5) Check off and describe the option used to satisfy the Screen and Enroll requirement before a child may be enrolled under title XXI. LJ (a) Screening threshold established by the Medicaid agency as: i I (i) _ percentage of the Federal poverty level which exceeds the highest Medicaid income threshold applicable to a child by a minimum of30 percentage points: specify __________________________________________ ; or r-1 (ii) _ percentage of the FPL (describe how this reflects the value of any differences between income methodologies of Medicaid and the Express Lane agency: ); or [I (b) Temporary enrollment pending screen and enroll. TN No.: JO-otj Approvai~P--2-i.-2010 Effective Date otfjol /e?rJ If> Supersedes TN No.: IJI:;."lA)

STATE PLAN UNDER TITLE XIX OF TilE SOCIAL SECURITY ACT State: rvlaryland Medical Assistance Program Page 1\d Citation(s) TN No.: Jl>- OCf Supersedes -.. 1 TN No.:~ SECTION 2 - COVERAGE AND ELIGIBILITY 2.1 Application, Determination of Eligibility and Furnishing Medicaid (Continued) r<l (c) State·s regular screen and enroll process for CHIP. i.J (6) Check off if the State elects the option for automatic enrollment without a Medicaid application, based on data obtained from other sources and with the chird's or family's affirmative consent to the child's Medicaid enrollment. [ .1 _; (7) Check off if the State elects the option to rely on a finding from an Express Lane agency that includes gross income or adjusted gross income shown by State income tax records or returns. Approval ~p 2 8 2010 Effective Date 0 'I/ 0 '/ ~ 0 I()

- - DEPARTMENT OF IlEALTil AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERV1CES~:_______-,-______---___---=-:==----....-::--::-:~o:::.:,~::=:m:...:r-;.:..;;;·o;;;.;,09;..;.3::..::&...:..{l.:.,:.19;;;..3_ TRANSMITTAL AND NOTICE OF APPROVAL OF 1, TRANSMJTIAL NUMBER: 2. STATE STATE PLAN MATERIAL 10-09 Maryland FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAJD) TO: REGIONAL ADMINJSTRA TOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE April 1, 2010 5. TYPE OF PLAN MATERIAL (Check Olle): u NEW STATE PLAN !J AMENDMENT TO BE CONSIDERED ~S NEW PLAN X AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (.."1eparale Transmillalfor each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: ! 7. FEDERAL BUDGET IMPACT: §203 of the Children's Health Insurance Program Reauthorization Act 0[2009 (CHIPRA), Public Law 111­ 3 8. PAGE NUMBER OF THE PLAN SECTJON OR ATTACHMENT: 2.1 Page llb 2.1 Page lIe 2.1 Page lId a. FFY 2011 $ 0 b. FFY 2012 "$ 0 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACH1I.1ENT (JfApplicahle): NEW NEW New 10. SUBJECT OF AMENDMENT: Express Lane Eligibility for 11. GOVERNOR'S REVIEW (Check One): o GOVERNOR'S OFFICE REPORTED NO COMMENT X OTHER, AS SPECIFlED: The Secretary of the o COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Department ofHealth and Mental Hygiene o NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMlTTAL AGENCY OFFICIAL: 16. RETIJRN TO: Susan Tucker -3-1'-·,(!~~~~~~=-=---:.------------·-l ExecLltive Director 1 . _-.-:::.=--____~____________~ Office ofHealth Services 14. TITLE: Secretary, Department of Health & Mental Department of Health & Mental Hygiene ..--___1 201 W Preston St, 1 51 floor Baltimore MD 21201 12. -----,-=-=-:~____---~--------- FORM CMS-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for ~tedicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS for MEDICARE (I MEDICAID SERVICES Region IIIjDivision of Medicaid and Children's Health Operations 2 March 2011 Susan J. Tuckcr Acting Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Suite 525 Baltimore, MD 21201 Dear Ms. Tucker: Enclosed is a copy ofthe approved State Plan Amendment (SPA), Transmittal Number 10-13. This SPA ensures compliance with the Qualifying Individual Program Supplemental Funding Act of 2008, whereby the State has an eligibility determination system that provides for data matching with medical assistance programs operated by other States in order to prevent duplicate enrollments. The effective date for this amendment is October 1,20 I O. The signed CMS-179 form and the approved State Plan pages are enclosed. It has been determined that this SPA does not have a direct impact on Indians or the Maryland Urban Indian Organization (which is the only Indian health program in the State); however, the State is reminded to continue following agreed-upon procedures for seeking advice from the Maryland Urban Indian Organization in advance ofsubmitting any SPA or Waiver having a direct impact on Indians or the Urban Indian Organization. If you have questions about this SPA, please contact Rosemary Feild, at (215) 861-4278. Sincerely, /s/ Ted Gallagher Associate Regional Administrator Enclosure cc: Debbie Ruppert MD DHMH Rebecca Hyman MD DHMH

ATTACHMENT 4.32 Page 1 State Plan Under Title XIX Of The Social Security Act State: Maryland INCOME AND ELIGIBILITY VERIFICATION SYSTEM The Medicaid agency has established a system for income and eligibility veritlcation in accordance with the requirements of42 CFR 435.940 through 435.960. (Section 1137 oCthe Act and 42 CF'I~ 435.940 through 435.960) (c) ATTACHMENT 4.32-A describes in accordance with 42 CFR 435.948(a)(6) the infonnation that wiI! be requested in order to verify eligibility or the correct payment amount and the agencies and the Statc(s) from which that information will be req nested. The State has an eligibility determination system lhat provides for data matching through the Public Assistant~e Reporting Infonnaiion System (PARIS), or any successor system, including 111<ltching with medical assistance programs operated by other States. The information that is requested will be exchanged with States and other entities Icgal1y entitled to verify title XIX applicants and individuals eligible for covered title XIX services consistent with applicable PARIS agreements. MAR 0 2 2011' . . TN No. 10-13 Approval Date __~__,"_Effective Date: 0 em CG7< I, dO I 0 Supersedes TN No. New

ATTACHMENT 4.32-A Page I State Plan Under Title XIX Of The Social Security Act State: Maryland TNCOME AND ELIGIBILITY VERIFICATION SYSTEM PROCEDURES REQUESTS TO OTHER STATE AGENCIES A description of the system used hy Maryland State Agency is listed below: Maryland has been a member of the PARIS Project every quartef sincc August 1999. Using the Social Security Number of recipients as the key, the match process compares benefit payouts made by States for TANF (TCA), SNAP (known in Maryland as Food Supplement Program (FSP) and MA against various databases. There arc three pmts of the PARIS data match proccss. The Veterans Administration (VA) database match determines ifan individual is collecting V A benefits. The Interstate match compares participating Stales data against eaeh other and determines ifan individual is collecting benefits in more than one State. The Federal match detennincs whether anyone receiving benefits is also colleeti11g a salary or retirement pension as a euncnt or fbrmer U.S. military or civil service employee. The federal PARTS computer facility perforl11s the data match and provides any hits to the State. State staff verify the data and follow appropriate veri lication procedures and adverse action. The Family Investment Administration has added three new Alert screens in Client Automated Resource and Eligibilily System (CARES) 1'01' the receipt and filtering ofthe three types of PARIS matches: V A, Interslate and Federal. Effective December 26, 2006, automation oflhe receipt and filt.ering of the PARIS matches began. Automation reduces the time spent on manual review and filtering and action on duplicate benefits. '111e matches arc sent directly through the CARES system to tbe local Social Services offices or the local Health Departments. These matches are reviewed by the case manger and are coded into lhe system. Any match w'hich can not be completed is referred to the MD Office ofTnspcclor General (OIG) f()r invesligation. In addition the OIG has access to the alerts allowing the tracking and monitoring or matches. TN No. jO-13_ Approval Date::UAR, 02 2.Off' Effective Datc:...f).t:l12J(;b'R. " c3f)J D Supersedes TN No. 88-9

FEDERAL REGULATION CITATIONS: SPA 10-13 Attachment 2.2A 42 CFR 435.10 Attachment 2.6A 42 cm Part 435, Section 435.10 and Subparts G&H AT·78-90, AT-&O-6, AT-80-34, 1902(1) and (n)ofthc Act, P.L. 99-509 (Sees. 9401 and (402),1902 (I) and (n) and 1920 ofthe Act, P,L. 99-509 (Sees. 9401,9402, and 9407) Attachment 3.IA Part 400, Subpart Band 1902(c)(5), 1905(a)(18) through (20), and 1920 ofthe Act, P.L. 99-272 (Sections 9501,9505 and 9526) and 1902(a), 1902(a)(47), 1902 (e)(7) through (9), and 1920 of the Act, P.L. 99-509 (Sections 940 l(d), 9403, 9406 through 9408) and P.L. 99-514 (Section 19Wi(c)(3» Attachment 3.1 B 42 eFR Pari 440, Subpart B, 42 CFR 441. 15, A T-78-90, A T-80-34 Attachment 3.IC 42 eFR 431.53, AT-78-90 Attachment 3.1 F 1905(a)(24) and 1930 of the Act, P.L. 10 1-508 (Section 4712 OURA (0) Attachment 4.18A 447.51 through 447.58 Attachment4.18C 447.51 through 447.58 Attachment 4.18-F 447.50-447.5Q Attachment 4.19 A&B (a) 42 CFR 447.252,46 FR 44964,48 FR 56046, 50 FR 23009, 1902(e)(7) oflhe Act, P.L. 99-509 (Section 9401(d» (b) 42 eFR 447.201,42 CFR 447.302, AT-78-90, AT-&0-34, J903(a)(I) and (n) and 1920 ofthe Act, P.L. 99·509 (Section 9403,9406 and 94(7), 52 FR 28648 Attachment 4.16 42 CFR 431.615(c) AT-78-91l Attachment 4. [9D (d) 42 CFR 447.252, 47 FR 47964, 48 FR 56046,42 CFR 447.280, 47 r-R 31518, 52 FR 28141 Attachment 4.22A (a) 4J3.137( a), 50 PR 46652,55 FR 1423 Attachment 4.22B (b) 433.138(f), 52 FR 5967,433.1 38(g)( 1 )(ii) and (2)(ii), 52 FR 5967, 433.I3J(g)(3)(i) and (iii), 52 FR 5967, 433. 138(h)(4)(i) through (iii), 52 FR 5967 Attachment 4.22C Section 1906 of the Act Attachment 4.26 1 927(g) 42 eFR 456.700, J 927(g)( 1 )(A), 1 927(g)( 1 )(a) 42 CFR 456.705(b) and 456.709(b), 1927(g)(l )(8) 42 CFR 456.703(d) and (0. I927(g)( I)(D)42 CFR 456.703(b), 1927(g)(2}(A) 42 eFR 456.705(b), J927(g)(2)(A)(i) 42 eFR 456.705(b), I927(g)(2)(A)(i) 42 CFR 456.705(b), (I )-(7), 1 927(g)(2)(A)(ii) 42 CFR 456.705(c) and (d), 1927(g)(2)(B) 42 eFR 456.709(a), 1927(g)(2)(C) 42 CFR 456.709(b), J927(g)(2}(D) 42 CFR 456.711, 1927 (g)(3)(A) 42 eFR 456.716(a), 1927 (g)(3)(8) 42 erR 456.716 (A) and (8), J927(g)(3)(C) 42 CFR456.7J6 (d) 1927(g)(3)(C) 42 CFR 456.711 (a)-(d), 1927 (g)(3)(D) 42 CFR 456.712 (A) and (8), 1927(b)(1) 42 CFR 456.722, 1927(g)(2)(A)(i) 42 CFR 456.705(b), 1927(j)(2) 42 CrR 456.703(c) ~__ Attachment 4.J2A (n) 435.940 through 435.960,52 FR 5967 Attachment 4.33A (a) 1902(a)(48) of the Act, P.L. 99-570 (Section 11005), P.L. 100-93 (Section 6(a)(3» Attachment 4,35A (a) 1919(b)(I) and (2) of the Act, P. L. lOO-1 03 (Section 4212(a» Attachment 4.35B (b) Same as above

12. DEPARTMENT OF HEALTH AND HUMAN SERVICES FORl\l APPROVED CENTERS FOR },ffiDlCARE &, MEDICAID SERV1CES OMB NO 0938'(lI93 TRANSMITTAL AND NOTICE OF APPROVAL OF 2. STATE STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER: Maryland 10-l3 FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3, PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTI VB DATE CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR October I, 2010 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): [l NEW STATE PLAN C AMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT COMPLETE BLOCKS 6 THRll 10 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment) ____-=-=:.:.-::.=-:::::==-=~..:-=-:=...:..::.,.:.:-.:..:c:.:~:::...:.::::..:...:..=;:..:..:.:=::::::...:..~=::.:...:::.:.:::.-:..::..::::..::=:.;;.::::,L:.;.....:.::..:.;.:...;.;.===~-,--­ 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Section 1903(r) of the Social Security Act a, FFY 20 11 ~ 0 &r s'u ffLEft{;jIJJJfL FVjJD/IIlC I}C:,t'r b. FFY 2012 ~ 0 8. PAGE NUMBER OF TI1£ PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION A TTACHMENT: OR ATTACHMENT (IfApplicable): Page I, Attachment 4.32 New Page 1, Attachment 432-A Page 1, Attachment 4.32-A (88-9) -----~------- .•. --­ 10, SUBJECT OF AMENDMENT: Provides for the documentation ofparticipation in the Public Assistance Reporting Information System (PARIS) project or any successor system, as required by the provisions of the Qualifying Individual Program Supplemental Funding Act of 2008 (the QI Funding Act). This amendment ensures that individuals enrolled in Medicaid or other public assistance benefits in one State are not receiving duplicate benefits based on simultaneous enrollment in the Medicaid program or other public benefit programs in another Sta.c.cte:...;...___________. II. GOVERNOR'S REVIEW (Check One): o GOVERNOR'S OFFICE REPORTED NO COMMENT X OTHER, AS SPECIFIED: The Secretary of the o COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Department of Health and Mental Hygiene o NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL OF STATE A}1ENCY OFFICIAL: 16. RETIJRN TO: /II"--~ Jt./ G . .Ji~. Susan Tucker -1-3-,--r--f'N-A-M-E-:-=]-oh:-n-.-=-M-=-,'-C="',o-::l-=m:;;;;Ce-rs-'----------1 Executive Director ____-::;-__--::::--___---:_-....,-.,--_____--1 Office of Health Services 14. TITLE: Secretary, Department of Health & Mental Department of Health & Mental Hygiene ..~~~j"j'n,~~:r;_:_-~------------~_j 201 W Preston St, l~t floor 15. DATE Baltimore MD 21201 fORM CMS-179 (07-92)

., DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 Region Ill/Division of Medicaid and Children's Health Operations Charles J. Milligan, Jr. Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Suite 525 Baltimore, MD 21201 Dear Mr. Milligan: We are pleased to inform you that Maryland State Plan Amendment-Number 11-03 has been approved. This amendment extends outpatient psychiatric care as a physician service through video telemental health technologies for eligible individuals in designated rural areas. The effective date is January 1, 2011. The signed CMS-179 and the approved State Plan pages are enclosed. If you have any questions regarding this amendment, please contact Rosemary Feild at (215) 861-4278. Sincerely, ~~6~ Ted Gallagher Associate Regional Administrator Enclosure Do vou know someone who has heen denied medical insurance bC'cause cJ(a pre-exisling co11dition! flso. thev maj: be eligible for the 11cw Pre-Existing Co11dilion lnsura/lce Plan. Calltollji·l!e 1-866-717-58:!6 rTTY 1- 866-561-160./) or Fisit WWl1-'.pcip.gol' and click on "Find Your Slate ·· /o learn more.

FEDERAL REGULATION CIT/\ TIONS: SPA I 1-03 Attachment 2.2/\ 42 CFR 435.10 Attachment 2.6A 42 CFR Part 435. Section 435.10 and Subparts G&H AT-78-90, AT-80-6, AT-80-34. 1902(1) and (n) of the Act. P.L. 99-509 (Sees. 9401 and 9402), 1902 (I) and (n) and 1920 of the Act. P.L. 99-509 (Sees. 9401.9402. and 9407) ..A.. Attachment 3.1 A Part 400. Subpart Band 1902(c)(5). 1905(a)( 18) through (20). and 1920 of the Act. P.L. 99-272 (Sections 950 I. 9505 and 9526) and 1902(a). 1902(a)(47). 1902 (e)(7) through (9), and 1920 of the Act. P.L. 99-509 (Sections 940 I (d). 9403. 9406 through 9408) and P.L. 99-514 (Section 1985(c)(3)) Attachment 3.1 B 42 CFR Part 440. Subpart l3. 42 CFR 441 .15. AT-78-90. AT-80-34 Attachment 3.1C 42 CFR 431.53. AT-78-90 Attachment 3.1 F I <J05(a)(24) and 1930 of the Act. P.L. I 01-508 (Section 4712 OBRA 90) Attachment4.18A 447.5 1 through 447.58 Allachment 4.18C 447.51 through 447.58 Attachment 4.18-F 447.50-447.59 __ X __ Attachment 4.19 /\&B (a) 42 CFR 447.252. 46 FR 44964, 48 FR 56046. 50 FR 23009. 1902(e)(7) of the Act. P.l.. 99-509 (Scction9401(d)) (b) 42 CFR 447.20 I. 42 CFR 447.302. AT-78-90, AT-80-34, 1903(a)( I) and (n) and 1920 of the Act. P.L. 99-509 (Section 9403. 9406 and 9407). 52 FR 28648 Attachment 4.16 42 CFR 431 .615(c) AT-78-90 Attachment 4.190 (d) 42 CFR 447.252. 47 FR 47964. 48 FR 56046. 42 CFR 447.280. 47 FR 31518. 52 FR 28141 Allachment 4.22/\ (a) 433.137( a). 50 FR 46652. 55 FR 1423 Attachment 4.22B (b) 433.138(t). 52 FR 5967. 433.138(g)( I )(ii) and (2)(ii), 52 FR 5967. 433.133(g)(3)(i) and (iii). 52 FR 596 7. 433.138(h)( 4)(i) through (iii). 52 FR 5967 Attachment 4.22C Sect ion 1906 of the Act Attachment 4.26 1927(g) 42 CFR 456.700. 1927(g}( I)( A), 1927(g)( I )(a) 42 CFR 456. 705(bl and 456.709(b), 1927(g)(I)(B)42 CFR 456.703(d) and (t). 1927(g)(I)(D) 42 CFR 456.703(b). 1927(g)(2)(A) 42 CFR 456.705(b). 1927(g)(2)(A)(i) 42 CFR 456. 705(b). 1927(g)(2)(A)(i) 42 CFR 456.705(b). (I )-(7). 1927(g)(2)(A)(ii) 42 CFR 456.705(c) and (d). 1927(g)(2)(B) 42 CFR 456.709(a). 1927(g)(2)(C) 42 CFR 456.709(b), 1927(g)(2)(D) 42 CFR 456.71 I. 1927 (g)(J)(A) 42 CFR 456.716(a), 1927 (g)(3)(B) 42 CFR 456.716 (A) and (B). I <)27(g)(3)(C) 42 CFR456.716 (d) 1927(g)(3)(C) 42 CFR 456.711 (a)-(d), 1927 (g)(3)(D) 42 CFR 456.712 (A) and (B). 1927(b)( I) 42 CFR 456.722, 1927(g)(2)(A)(i) 42 CFR 456.705(b). 1927(j)(2) 42 CFR 456.703(c) Attachment 4.32/\ (a) 435.940 through 435.960, 52 FR 5967 Attachment 4.33A (a) 1902(a)(48) oft he Act, P.L. 99-570 (Section II 005). P.L. 100-93 (Section 6(a)(3)) Attachment 4.35A (a) 1919(b)(l) and (2) ofthc Act. P.L. 100-103 (Section 4212(a)) Attachment 4.35 13 (b) Same as above Attachment 4.44 Section 1902(al(80) of the Act. P.L. 111-148 (Section 6505)

Attachment 3 .1-A Page 17 STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND PROGRAM LIMITATIONS 5. Physicians' services whether A. The Physician Program covers furnished in the office, the patient's medically necessary physician services home, a hospital, a skilled nursing when the services are provided by facility or elsewhere. licensed physicians. When a service is provided as part of a health-related service in schools or in the child's home, it must be determined necessary and included as part of a child's IEP or IFSP. B. Physician Services which are not covered are: I. Services not medically necessary; 2. Physician services (other than those for pregnant women and children) denied by Medicare as not medically necessary. For pregnant women and children, the state will review for medical necessity even if Medicare has denied the coverage; 3. Nonemergency dialysis services related to chronic kidney disorders unless they are provided in a Medicare-certified facility; 4. Services which are investigational or experimental; 5. Autopsies; 6. Physician services included as part of the cost of an inpatient facility, hospital outpatient department, or free-standing clinic; 7. Payment to physicians for specimen collection, except by venipuncture and capillary or TN No. 11-03 Approval Date 'JUN 13 2M1~ Effective Date .;:ri}NuJ---8y /1 ..ZeJ I/ Supercedes TN No. I 0-04

PROGRAM Attachment 3.1-A Page 17-C STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND LIMITATIONS 5. Physicians' services whether furnished 2. Cosmetic surgery - ?reauthorization in the office, the patient's home, a will determine whether there is hospital, a skilled nursing facility or medical documentation that the elsewhere. physical anomaly being addressed by the surgery represents a significant deviation from the normal state and affects the patient's health to a degree that it impairs his or her ability to function in society; 3. Consultations provided by physicians specializing in radiology or pathology; 4. Lipectomy and panniculectomy - ?reauthorization will determine whether there' is an abnormal amount of redundant skin and subcutaneous tissue which is causing significant health problems for the patient; 5. Transplantation of vital organs; 6. Surgical procedures for the treatment of morbid obesity; and 7. Elective services from a non- contiguous state. 8. Telemental Health Services - Services for telemental health services are subject to identical preauthorization requirements as face-to-face services. An individual is eligible for services through the public mental health system (PMHS) if the services are preauthorized, if required, by the Administration's administrative services organization (ASO). TN No. 11-03 TN No. 10-04 'JUN 13 2011 Approval Date t Effective Date J'"'I}NLtA-1\f I, 02 6 J I

Attachment 3.1-A Page 17-D STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND PROGRAM LIMITATIONS 5. Physicians' E. Certain surgical procedures identified under "Inpatient services whether Services" (Attachment 3 .I A page 128 number 11) must be furnished in the preauthorized when performed on a hospital inpatient basis office, the unless: patient's home, a 1. hospital, a skilled The patient is already a hospital inpatient for a medically nursing facility necessary condition unrelated to the surgical procedure or elsewhere. requiring preauthorization, or 2. An unrelated procedure which requires hospitalization is beipg performed simultaneously. F. Telemental health, as defined in COMAR 10.21.30 provides an alternate method of delivering psychiatric consultation, evaluation, and ongoing treatment to improve access for eligible individuals requiring outpatient psychiatric care in an approved distance format to improve capacity and choice for ongoing psychiatric treatment. Telemental Health service delivery requires the following provisions to be met: 1. Providers must: a. be a Maryland-licensed psychiatrist and have a Medicaid provider number or be practicing in an Outpatient Mental Health Clinic (OMHC) or Federally Qualified Health Center (FQHC). b. submit an application to MHA that describes how the originating site and distant site will comply with the regulations including any and all contractual relationships and billing procedures for this service: Telemed services are covered in CO MAR 10.21.30 and accessible through the following link: httQ:LLwww.dsd.state.md.usLcomarLSubtitleSearch. asQx?search= 10.21.30. 2. Telemental health must be delivered via a live interactive audiovisual communication video method limited to a telehealth health originating site that is an OMHC or FQHC that provides live, audiovisual communication between the provider and client. TN No. 11-03 Supercedes TN No. 09-08 Approval Date: •JUN 13 3Jft· Effective Date: ::T/tAI tMBV I 1 07 0 II

TN No. 11-03 Attachment 3.1-A Page 17-E STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND 3. Telemental health services are limited to residents in designated rural geographic areas. 4. The telemental health originating site is limited to the designated rural geographic areas; the distant site may be located anywhere within the State of Maryland. 5. Telemental health services will be billed to Medicaid in the same way as face-to-face mental health services are billed except that the distant site psychiatrist will add the "GT" modifier to the mental health procedure code indicating the delivery mode (Telehealth). 6. Telemental health services are limited to individual psychotherapy, pharmacologic management, and a psychiatric diagnostic interview examination provided by a distant site psychiatrist. 7. The originating site may bill only for a licensed mental health professional "telepresenter" if the distant site psychiatrist documents in the individual's medical record the medical necessity for the direct face-to-face participation of the telepresenter. 8. The originating site will bill Medicaid using the Q3014 facility fee code. 9. All preauthorization requirements for mental health services must be met before engaging in the provision of telemental health services. Supercedes TN No. NEW Approval Date: 'JUN 13 2(1'tf'i Effective Date: u/TN'u,4-l{.v /,dOll ,

Attachment 4.198 Page 6A STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of Maryland SA. Reimbursement for Teiemental Health Services: SA-a. Reimbursement for Telemental health services delivered in accordance with services described in Attachment 3.1-A pages l7C through l7E as distant site practitioners, including physicians, are paid using the fee schedule through the link to Value Options, Maryland's Behavioral Health Provider: http://marvland.valueoptions.com/provider/cliams ftnance/PMHS Reimbursement Schedule.pdf The agency's fee schedule rate was set as of July I, 20 II and is effective for services provided on or after that date. Except as otherwise noted in the Plan, State developed fee schedule rates are the same for both governmental and private individual practitioners. SA-b. Reimbursement for Telemental Health is limited to individual psychotherapy, pharmacologic management, and a psychiatric diagnostic interview examination. These services are provided in increments of20-30 or 4S-SO minutes. The unit of service is the same for the distant site and the originating site. SA-c. Services for Telemental Health must be provided by a Maryland-licensed psychiatrist. SA-d. The distant site psychiatrist will bill using an allowable billing code with the GT ("telehealth service") modifier. The physician and originating site fee may be located through the link referenced in SA-a through Value Options. SA-e. Originating or Spoke Site or Location of Medicaid Recipient: TN 11-03 Supersedes TN NEW e-i. The originating site must be an OMHC or an FQHC located in a designated rural geographic area. e-ii. Reimbursement for Telemental health transmission costs is set at the current Medicare rate for the originating site facility fee and is set based on the Medicare Economic Index (MEl) at 80% of the lesser or actual charge. e-111. The originating site will bill using the HCPCS Level II code Q30 14, telemedicine facility fee." e-iv. The originating site may not be reimbursed for the services of the distant site provider. e-v. The originating site may only be reimbursed for the services of a licensed independent practitioner if the distant site psychiatrist documents in the individual's medical record the medical necessity for the direct face to face participation of the telepresenter at each session. Only when the medical necessity has been determined and documented may the telepresenter bill the applicable CPT code for the service rendered. YJUN 11 1111- -- Approval Date Effective Date ..:.J /1-Alll At< V /, ~0 J/

DEPARTMENT OF HEALTH AND HUMAN SERVICFS HEALTH CARE FINANCING ADMINISTRATION FORM APPROVED OMB NO 0938-0193 TRANSMITTAL AND NOTICE OF API'ROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEAL HI AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One}: I. TRANSMITrAL NUMBER: 11-03 2. STATE Maryland 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE January I, 20 I I 0 AMENDMENT TO BE CONSI ::.D~ ER;-=.1-'~ : D~A~S~ N:..:.:E~W:.....:....:PI~ . I~ \ N-:::----:-.::IZJ;:7.-A~M.:.::E=-:N-D:._M_EN-;T---:-___ _ COMPLETE BLOCKS 6 THRU 10 _IF Tl liS IS AN A~IEND~-~J::l.I .G~eqrate 7hmsmillal[or each amendmem) I NEW STATE PLAN 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Attachment 3. I A a. FF'{ 2011: $ 0 Attachment4.19H b. FFY 2012:$ 0 8. PAGE NUMBER OF THE PLAN SECTION OR ·-- - -- 9." PAGi::N·.,'"'"t ""'" JI\-:" ,H':=lE~ ~ R~O~F~T~H~E~S~l~JP~E~R~S~E~D'::E::::D:-:P:::L-A:-::N-:-:::S:::-EC=T:-::10::-::N-:--- AlTACHMENT: OR A ITACHMENT (ljApplicab/e): 3.1-Ap.l7: ~-1 -Ap . I7(10-0·I) 3.1-A p.I7-C: 3.1-A p.17C (10-04) 3.JA p.I7D 3.1-A p.17D(09-08) 3.1A p. 17 E: 3.1-A p. I7E (NEW) 4.198 page 6A 4 . 191!~gc 6A (NEW) 10. SUBJECT OF AMENDMENT: To improve access to outpatient psychiatriC care for eligible individuals via video telemental health technologies to designated rural geographic areas. Adding these services will reduce emergency room, inpatient, and detention center admissions; and improve capacity and choice for ongoing psychiatric treatment. II. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUI1MITTAL " 12.SIGNATUREOFS~~ ''"'' "'.:.FICIAL: J-3. TYPED NAME: Jo'sh6a M. Sharfstein, M.D. 14. TITLE: Secretary, Department of Health & Mental Hygiene 15.DATESUBMITTED: /iJt(~Cf/ !'l rJt}J/ . I [8) OTI-IER, AS SPECIFIED: Susan J. Tucker, Executive Director Ofticc of Health Services 16. RETURN TO: Susan J. Tucker. Executive Director OTIS-DHMH 201 W. Preston St., 1st floor Baltimore. MD 21201 .• , . . :-:. . FOR REGIONAL OFFICE USE ONLY .... :.. ~ . FORM HCFA- I 79 (07-92) .·· . ', .

·DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 aNTERS frJr MEDICARE & MEDICAID SEIMCES Region II@ivision of Medicaid and Children's Health Operations JUN 9 2011~ Charles J. Milligan, Jr. Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Suite 525 Baltimore, MD 21201 Dear Mr. Milligan: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 11-04. This amendment clarifies compliance with July 1, 2010 guidance from the Centers for Medicare and Medicaid on Section 214 ofthe Children's Health Insurance Program Reauthorization Act (CHIPRA). This SPA serves to update Maryland SPA 09-07, effective April1, 2009, which provides coverage to qualified alien children with incomes up to 300 percent of the Federal Poverty Level (FPL) and qualified alien pregnant women with incomes up to 250 percent FPL, in accordance with Section 214 of CHIPRA. We understand that the State expanded its definition of those qualifying under this provision in July 2010, conforming to the July 1, 2010 CMS guidance. The effective approval date for this amendment is January 1, 2011. The signed CMS-179 form and the approved State Plan pages are enclosed. If you have questions about this SPA, please contact Rosemary Feild at 215-861-4278. Sincerely, ~~~i: Ted Gallagher Associate Regional Administrator Enclosure

Revision: CMS-PM- ATf ACHMENT 2.6-A Page 2 OMB No.: STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State : Maryland ELIGIBILITY CONDITIONS AND REQUIREMENTS Citation(s) Condition or Requirement 42 CFR 435.406 3. Is residing in the United States (U.S.), and-- TN 11-04 Supersedes TN 09-07 a. Is a citizen or nationnl of the United States; b. Is a qualified alien (QA) as defined in section 431 of the Personal Res'ponsibility and Work Opportunity Reconciliation Act of 1996 (PR WORAt as amended, and the QA ·s eligibility is required by section 402(b) of PR WORA as amended. and is not prohibited by section 403 of PR WORA as amended: c. Is a qualified alien subject to the 5-year bar as described in section 403 ofPRWORA. so that eligibility is limited to treatment of an emergency medical condition as defined in section 40 I of PRWORA: d. Is a non-qualitied alien, so that eligibility is limited to treatment of an emergency medical condition as defined in section 40 I of PRWORA: e. Is a QA whose eligibility is authorized under section 402(b) of PR WORA as amended, and is not prohibited by section 403 of PRWORA as amended. _ll_ State covers all authorized QAs. State docs not cover authorized QAs. f. State elects CHIPRA option to provide full Tv1edicaid coverage to otherwise eligible pregnant women or children as specified below who arc aliens lawfully residing in the United States: including the l(>llowing: Approval Dat~~~-~ 9 2011' Effective Date 01jN[{41<. y /1 OZ () I I

Revision: CMS-PM- ATTACHMENT 2.6-A Page 2a (I) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. § 1641 ); (2) An alien in nonimmigrant statlls who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) ofthe Immigration and Nationality Act (INA) (8 U.S.C. § 1182(d)(5)) lor less than I year. except f()r an alien paroled lor prosecution. for deferred inspection or pending removal proceedings: (4) An alien who belongs to one of'lhc follov,'ing classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively): (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. § l254a). and pending applicants for TPS who have been granted employment authorization: (iii) Aliens who have been granted employment authorization under 8 CfR 274a.l2(c)(9), (I 0). (16). ( 18). (20). (22). or (24); (iv) family Unity beneficiaries pursuant to section 30 I of Pub. L. 101-649, as amended: (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President: (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and \-Vho have a pending application for adjustment of status: (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241 (b)(3) of the JNA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization. and such an applicant under the age of 14 who has had an application pending for at least 180 days; (6) An alien who has been granted withholding or removal under the Convention Against Tm1ure; · (7) A child who has a pending application lor Special Immigrant Juvenile status as described in section 101(a)(27)(J) ofthe INA (8 U.S.C. § ll01(a)(27)(.1)): TN 11-04 Supersedes TN 09-07 'JUN Approval Date __ _ 9 2011 Effective Date V/fAJIAA~ <j I 1 d--eJ If

Revision: CMS-PM- ATTACHMENT 2.6-A Pugc 3 (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. * 1806(e): or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa. _x_ Elected for pregnant women. _]L Elected for children under age __11 __ _. TN I 1-04 Supersedes TN _09-07 g. _]L__ The State provides assurance that tor an individual whom it enrolls in Medicaid under the CHIPRA section 214 option, it has verified. at the time of the individual's initial eligibility Jetennination and at the time of the eligibility redetermination that the individual continues to be lawfully residing in the United States. The State must tirst attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available. it must require the individual to provide documentation or further evidence to verify satislactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 113 7(d) of the Act. ApproYal Dat~JUN 9 2011 Effective Date VfJ-IU' L/ 1-lfy I, ;;)-()-11

DEP RTME T OF HFALTII AND I lUMAN SERVICES IIE/\LTII ARE FJN,\NCING Dl\11 ISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID ERVICE TO: REGIONAL ADMINISTRATOR E TERS FOR MEDICARE eM ~ DJCAID SERVI F::S DEPARTME T OF HEALTH A D IIUMA SERVICE 5. TYPE OF PLAN MATERIAL (Ch<!c:k One): Pages 2, 2a 3, Attachment 2.6A UMBER: 3. PROGRAM IDE TIFICATION: TITLE XIX OF THE OCIAL ECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE January I. 20 II a. FF 9. PAG E MBER OF THE UPERSEDED PLAN SECTIO OR TTACIIMENT (~(Applicable): Pages 2. 3. Attachment2.6A (09-07) I 0. SUBJECT OF AMENDMENT: To provide for Medicaid/CHIP coverage to I) qualified alien children below the 5-year bar with incomes up to 300% FPL and 2) qualified alien pregnant women below the 5-year bar with incomes up to 250% FPL. expressly including all categories of aliens lawfully residing in the United tates as provide in CMS 110 letter II I 0-006, CHIPRA 11 17, dated I July 20 I 0. II. GOVERNOR' S REVIEW (Check One): 0 GOVER OR'S OFFICE REPORTED NO OMMENT 0 COMMENT OF GOVERNOR'S OFFICE E CLO ED 0 0 REPLY RE EIVED WITH I 45 DAYS OF SUBMIIf AL 12. IG ATURE OF STATE ~FICI/\L: 13. TYPED NAME: Joshua M. Sharf tein. M.D. 14. TITLE: Secretary. Department of Health & Mental H iene 15. DATE SUBMITTED: J :'rJ _._ ,t (_A 'Z. '6 I 17. DATE RECEIVED: f11;ff{CJ-/ 21. TYPED NAME: 23. REMARKS: FORM HCFA-179 (07-92) ~ OTIIER. AS SPECIFIED: u an .1. Tucker, Executive Director Office of' Health Services I 6. RETUR TO: Susan J. Tucker, Executive Director 011 - DHMII 20 I W. Preston St.. I ~ ~ floor Baltimore, MD 21201

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS frx MEDICARE & MEDICAID SE1IVKES Region IlljDivision of Medicaid and Children's Health Operations JUL 2 9 2011 Charles J. Milligan, Jr. Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Suite 525 Baltimore, MD 21201 Dear Mr. Milligan: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 11-06. This SPA updates the State plan to reflect current practices and language involving: • Election of medically needy and PACE services • Name of the State agencies setting provider standards and conducting surveys • Payment for inappropriate level of care days in hospital setting • Reference to outdated HMO language in the Vaccines for Children program • Outpatient drug claims processes and DUR methodology • Quality incentive payments to SNFs and ICFs • Delegation of authority for review of State plan material The effective date of this amendment is April 1, 2011. The signed CMS-179 form and the approved State Plan pages are enclosed. If you have questions about this SPA, please contact Rosemary Feild at 215-861-4278. Sincerely, -T-=i ~3~ Ted Gallagher Associate Regional Administrator Enclosure Do you know someone who has /wen denied medical i11.wrance because ola ere-existing condition :' /fw>. Thcl' 11/U)' be eligihlefor The J/eH' J>re-E-..;istinx (_ 'ondition /nsurw1(:e Plan. C 'a// toll.fi'ee /-866-717-58::6 (TTY 1- 8()()-5()1- / 60-1 J or Fisit www.pdp. gov and click 011 "Find Your Stale·· to leom more.

20 Revision: HCI' A-P 1-91-4 Augu t 199 I (BPD) OMB No: 0938 - State/Territory: Citation 42 FR Part 440. Subpart B 1902 (a)( I 0)( ) (iv) of the Act 42 CFR 440.220 1902(c) (5) of the Act TN II 11 -06 upcr edes TN # 2l:.LL_ 3. I Marvland Amount. Duration and Sco e of Services (continued): (a)(2) Meclicallv needy. This State plan covers the medically needy. The services described below and in ATTACHMENT 3. 1-B are provided. Services for the medically needy include: (i) If services in an institution for mental diseases (42 CJ· R of the Act 440. I 40 and 440.160) or an intermediate care facility for 42 CFR 440.220 the mentally rctarded (or both) arc provided to any medically needy group, then each medically needy group is pro idee! either the services listed in eetion 1905(a) (I) through (5) and ( 17) of the Act, or seven or the services listed in section 1905(a) (I) through (20). The services are provided as defined in 42 C'FR Part 440 Subpart A and in sections I 902. 190-, and I 915 of the Act. D ot applicable with re peel to nursc-midwi fe en1iccs under section 1902(a) ( 17). urse- miclwives are not authorized to practice in this tate. (ii) Prenatal care and delivery services for pregnant women. JUL 2 9 2011 . Appr val Date ______ Effect1ve Date f!-fJA I L I, CJ-o t- 1

Page 20c State of Marvland PACE State Plan Amendment itation 3.1 (a)(2) Amount. Duration and Scope of Services: 1905(a)(26) and 1934 X TN # 11-06 Supersedes T # 02-08 Medically eedy (continued) Program of All-Inclusive Care for the Elderly (PACE) services, a described and limited in Supplement 3 to Attachment 3.1 - A. ATTACIIME T 3.1 -B identifies services provided to each covered group of the medically need . (Note: Other programs to be oHered to Medically Needy beneficiaries would specify all limitations on the amount. duration and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. ln addition, other programs to be offered to ifedically Needy beneficiaries would also list the additional coverage- that is in excess of established service limits- for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population. this also is not applicable for this program.) Appro al Date JUL 2 9 2011 Effective Date f}-ff( tL r, d-d /;}

Revision: Citation 42CFR431 .610 AT-78-90 J\ T-80-34 TN# 11-06 HCF A-/\T-80-38 May _2, 1980 (BPP) 42 State: Maryland 4.11 Relations \ ith tancbrd-Setting and urvcy Agencies (a) The tate agency utilized by the ecretary to determine qualifications of institutions and suppliers of service to participate in Medicare is responsible for establishing and maintaining health standards for private or public institutions (exclu ive of Christian Science sanatoria) that provide services to Medicaid recipients. This agency is The State Department of Health and Mental Hygiene; Oflice of Health Care Qualitv (b) The State authority(ies) responsible for establishing and maintaining standards, other than those relating to health. for public or private institutions that pro\·ide ser\'iccs to Medicaid recipients is (are): (c) Same as above specified in paragraphs (a) and (b) above, that arc kept on file and made available to the llealth Care Financing Administration on request. Approval Date JUl 2 9 2011 Effective Date /Jfl~ II..- /) ;?() L 1 Super edes TN ff 74-07

Revision: Citation 42 FR 43 1.610 AT-78-90 A T-89-34 T1 H 11-06 upcrscdes T HCF A-AT-80-38 May :L. 1980 (BJ>P) 43 State: Maryland 4.11 (d) The State Department of llcalth and Mt:ntal Hygiene: Orrice of llcalth ·arc ualit (agency) which is the tate agency responsible lor licensing health institution . determines i r institutions and agencies meet the requirements for parti<.:ipation in the Medicaid progrnm. The requircmenL in 42 CFR 431.61 O(c). (f). and (g) are met. ApprovalDatc ~Ul 29 2011 EffectiveDateA-/IUL / 1 ;?{)ll

57 Revi ·ion: HCf A-PM-91 - 4 (BJ>D) AUGUST 1991 OMB No.: 0938- State/Territor : Citation 42 CPR 447.252 1902 (a)(IJ) and 1923 of the Act TN fl 11-06 Supersede· TN # 92-1 I Marvland 4.19 Pa ment for Services (a) The lcdicaid agency meet · the requirement of 42 FR Part 447. Subpart C and ections 1902 (a) (13) and I CJ2 of the Act ' ith respect to payment for inpatient hospital scn·iecs. ATTA 'H lENT 4.19-A describes the methods and standard. used to determine rates for payment for inpatient hospital services. ~ Inappropriate level of care days are covered and arc paid under the tate plan at lower rates than other inpatient hospital services, renccting the level of care actuall)' received. in a manner consistent with section 1861 (v)(I)(G)ofthe ct. D Inappropriate le cl of care days arc covered. Section 4.19 Pavment lor Services a). (above). applies to all ho pitals except acute general hospitals. The Medicaid gency reimburses for inpatient hospital services in ucutc general ho pi tal at rates set by the Maryland llealth . erviccs Cost Review Commission pursuant to a wai er issued by the H.ealth Care Financing Administration (Contract No. 600-76-0 140). Approval Date:JUl 2 9 2.011 Effective Date ftl /? JL I, ;;f)t f

Revi ion: HCFA-PM-94-8 (MB) OCTOBER 1994 66 (b) Statefferritory:___.M '"'-'-"a'-'-ry"-''l,..,a.:..:.nd,_ _ ______ _____ _ _ itation 4.19 (m) Medicaid Reimbur. ement lo r Administration of Vaccines 1928 (c)(2) (C) (ii) of the Act 1926 of the Act T # 11-06 uper cdes TN # 95-07 under the Pediatric Immunization Pro ram (i) A provider may impose a charge for the administration of a qualified pediatric vaccine as stated in 1928 (c) (2) (C) (ii) of the Act. \ ithin this overall provision, Medicaid reimbursement to provider . will be admini tered as follows. (ii) The State: sets a payment rate at the level of the regional maximum established by the DHHS Secretary. is a Univer. al Purchase State and sets a payment rate at the lc cl of the regional maximum establi hed in accordance with State law . .x_ sets a payment rate below the level of the regional maximum established b the DHHS Secretary. is a nivcr al Purchase State and ets a payment rate below the level of the regional maximum established b the Universal Purchase State. The State pay the following rate for the administration of a vaccme: (iii) Medicaid beneficiary access to immunizations is assured through the following methodology: Each child is assigned to a primary medical care provider. These pro iders are respon ible for providing EPSDT services, including immunizations. Approval Date -JUL 2 9 2011 Effective Date f1 f~ JL. I 1 ;;?-()if

74c Revision: HCF A-PM- (M B) OMBNo. Stateff e rrito ry:_....:.M .:..:.:.... A!.!.R ~Y.:..._I"" ~ A,_,_,_N'""' 0""------------- ~ itati on 1927 (g) (3) (C) 42 CFR 456.71 1 (a)-(d) 1927 (g) (3) (D) 42 CfR 456.7 12 (A)·and (B) 1927 (h) (1) 42 CFR 456.722 1927 (g) (2) (A) (i) 42 CfR 456.705 (b) 1927 (j) (2) 42 FR 456.703 (c) •u.s. G r o ·1993-J•I2-2J9:800 IJ TN # 11 -06 Supersedes TN II 93-25 G. 4. The interventions include in appropriate instances: - Information dissemination - Written. oral, and electronic reminders - Face-to-Face discussions - Intensified monitoring/ review of prescri bers/di spcnsers H. The State assures that it will prepare and submit an annual report to the . ecretary. which incorporates a report from the State DUR Board, and that the State will adhere to the plan . steps. and procedures as described in the report. I. 1. The State establishes, as its principal means of J. processing claims for covered outpatient drugs under this title, a point-of-sale electronic claims management system to perform on-line: - real time eligibi lity verification - claim data capture - adjudication of claims - assistance to pharmacists, etc. applying for and receiving pa mcnt. 2. Prospective OUR is performed using an electronic point of sale drug claims processing system. I lospi tals which dispense covered outpatient drugs arc exempted from the drug utilization rc icw requirement· of this ection when facilities use drug formulary systems and bill the Medicaid program no more than the hospital's purcha ing cost for such covered outpatient drugc. .JUl 29 2611 Approval Date Effective Date lfllf I L / ;J.fJ 11 J

79c Revision: HCF A-PM-90- 2 (BPD) JANUARY 1990 OMB No.: 0938-0193 State/Territory: _ _:M~a!...lry~lc~m-'-"d~----------- Citation 1919 (h) (I) and (2) of the Act, P.L. I 00-203 (Sec. 4213 (a)) 1919 (h) (2) (B) (ii) of the Act 1919 (h) (2) (F) of the Act TN # 11-06 Super edes TN # 90-10 4.35 Remedies for Skilled Nursing and Intermediate Care Facilities that Do Not Meet Requirement of Participation (a) The 1cdicaid agency meets the requirements of section 1919 (h) (2) (A) through (D) of the Act concerning remedies for skilled nursing and intermediate care facilities that do not meet one or more requirements of pa11icipation. A-IT ACHMENT 4.35-A describes the criteria for applying the remedies specified in section 1919 (h) (2) (A) (i) tlu·ough (iv) of the Act. Not applicable to intermediate care facilities: these services are not furnished under this plan. IRJ (b) The agency uses the following rcmedy(ies) (I) Denial of payment for new admissions. (2) Civil money penalty. (3) Appointment of temporary management. (4) In emergency cases. closure of the facility and/or transfer of residents D (c) The agency establishes alternative State remedies to the specified Federal remedies (except for tcrn1ination of participation). A TI ACHMENT 4.35-B describes these alternative remedies and speci lies the basis for their use. []] (d) The agency uses one of the following incentive programs to reward skilled nursing or intermediate care facilities that furnish the highest quality care to Medicaid residents: D (I) Public recognition [Jg (2) Incentive payments Appro aiDate:JUl 29 2011 EffectiveDate A-f/?IL I, ;;riJ I)

:1 • ' • 89 Revision: HCF A-PM-91- 4 (13PD) AUGUST 1991 OMB o.: 0938- State/Territory: Citation 42 CFR 430.12 (b) Marvland 7.4 State Governor's Review The Medicaid agency will provide opportunity for the Oflicc of the Governor to review State plan amendments, long-range program planning projections. and other periodic reports thereon. excluding periodic tatistical. budget and fiscal reports. Any comments made will be transmiued to the Health Can.: Financing Administration with such documents. []] ot applicable. The Governor - []] Does not wish to review any plan material. D Wishes to review onl~ the plan materials specified in the enclosed document. I hereby certify that I am authorized to submit this plan on behalf of State Department of Health ami Mental Hygiene Date: (Charles J. Milligan. Jr.) TN # I 1-06 Super edcs TN # 92- I I (Designated Single State Agency) (S1gna urc) Deputy Secretary I Iealth Care f inancing (Title) Approva l Date JUL 2 9 2011 Effective Date/1--M IL / 1 ;h) If

DEPARTMENT .OF HEALTH AND HUMAN SERVICES HEAL Til CARE FINANCING ADMINISTRATION FORM APPROVED OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL I. TRANSMilTAL NUMBER: . 11-06 2. STATE Maryland FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE 04/01 12011 ' NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 12] AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se orate Transmiual for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2011: $ 0 b. FFY 2012: 0 8. PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION AlTACHMENT: OR AlTACHM NT (If Applicable): Page 20 Page 74c Page 20 (92-11) Page 74c (93-25) Page 20c Page 79c Page 20c (02-08) Page 79c (90-1 0) Page 42 & 43 Page 89 Page 42 & 43 (74-07) Page 89 (92-11} Page 57 Page 57 (92-11) Page 66b Pane 66b 95-07) 10. SUBJECT OF AMENDMENT: To update Section l ofthe State plan to re.tlect current practices, update names of agencies, and to update letter of Governor· s review by current DHMH Secretary. II . GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 13. TYPED NAME: Charles J. Milligan, Jr. 14. TITLE: Deputy Secretary for Health Care Financing 15. DATE SUBMITTED: _ 1 j "':;::, 1()... I) {gJ OTHER, AS SPECIFIED: Susan J. Tucker, Executive Director Office of Health Services 16. RETURN TO: Susan J. Tucker, Executive Director OHS - DHMH 201 W. Preston St. 1 1 floor Baltimore. MD 21201 FOR REGIONAL OFFICE USE ONLY t ., . 17. DATE RECEIVED: h-'1 Af 118. DATE APPROVED: ,, ,,..,. _ 13 t 7-() II . "JUL 2 9 2011 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATU OF /L. II 21. TYPED NAME: rG'YJ (;,4-LLA--t!- 23. REMARKS: FORM HCFA-179 (07-92)

. DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS for M£/JICAIIE .t MEDICAID SE1MCES Region III/Division of Medicaid and Children's Health Operations SEP 9 2011 Charles J. Milligan, Jr. Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Suite 525 Baltimore, MD 2120 1 Dear Mr. Milligan: We are pleased to inform you that Maryland State Plan Amendment (SPA) Numberll-09 has been approved. This amendment updates certain State plan pages, including non-discrimination practices, methods of assuring high quality care, removal of language on guidelines for assessing cost effectiveness of employer-based group health plans, and the definition of a claim. The effective date of this SPA is April 1, 2011 . The signed CMS-179 and the approved State Plan pages are enclosed. The State's SPA 11-09 submission also included an update of language on transportation. It was determined during the review process that some of this language needs to be transferred to the State's cost allocation plan. The State asked to withdraw its transportation pages from this SPA, and a decision was made to pursue this matter through a separate SPA and revised cost allocation plan, for which CMS staff can provide technical assistance, as desired. The enclosed letter with this approval letter documents the process to be followed for CMS approval of the State's language on transportation. If you have any questions regarding this amendment, please contact Rosemary Feild at (215) 861-4278. Enclosures Do you knoll' someone who Jws ht!en denied 111edical insurance because c~fa pre-ex isling condition'! lfso. thev may he el igihle for the IWH' Pre-EYisting C 'ondition lnsurunce Plan. C..'a/1 tol!.fi·ee 1-866- 7]7-5lC6 rTTY l- 8{)6-561-lnO-IJ or visil www.pcitJ. gov ond click on "Find Your Stole·· to learn more.

70 R~o.~vision: I-ICFA-PM-94-1 (MB) FEBRUARY 1994 Statenerritory: Citallim 42 CFR 433.151 (a) 1902 (a) ( 60) of the Act 1906 ofthc Act TN fl .LL:_09 Sup~rscdcs TN # 94-12 MARYLAN~D~------------ 4.22 (continued) (I) The Medicaid agency has written cooperative :1grccrnents for the enforcement of rights to and collection or third party benelils :1ssigned to the State as a condition nf eligibility for medical assistance with the following: (Check as appropriate.) J State title JV-D agency. The requirements of42 CFR 433.152 (b) arc met. Other appropriate State agency (s) -- --·· Other appropriate agency (s) of another State-- Courts and law cnl(>rcement officials (g) The Medicaid agency assures that the State has in effect the laws relating to medical child support under section 1908 of the Act. (h) The Medicaid agency specifies the guidelines used in determining the cost cfTcctivcness of an employer-based group health plan by selecting one of the following. _The Secretary's method as provided in the State Medicaid Manunl. Section 3910 The State provides ml:lhods tor determining cost cftcctivencss on .i\IJACHMENT 4.22-C Approval Date -St~-~J01f Effective Dntc 1/ L~o II

R7 Revision: HCfA-PM-91- 4 (BPD) AUGUST 1991 OMB No.: 0938- State/Territory: Maryland Citation 45 C FR Parts 80 and 84 TN I! I )-o~ Supersedes TN # 92-1 I 7.2 Nondiscrimination In accordance with title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et. scg.), Section 504 ofthe Rehabilitation Act of I 973 (29 U.S.C. 70b). and the regulations at 45 CFR Parts 80 and 84, the Medicaid agency assures that no individual shall be subject to discrimination under this plan on the grounds of race. color. national origin, disability or age. In addition. in accordance with Maryland State Law and policy, the Medicaid agency assures that no individual shall be subject to discrimination under this plan on the grounds of sex, religion, marital status. and sexual orientation. The Medicaid agency has methods of administration to assure that each program or activity for which it receives Federal tinancial assistance will be operated in accordance \Vith title VI regulations and State Law. These methods f(Jr title VI are described in ATTACHMENT 7.2-1\. A I D s E p . . 9 2011 E t'f' . D "pprova ate ~ ect1ve ate t~-b J;otl I

Attachment 3.1 C STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State o 1· __ _:.;.M_,_,a"-'-r.J..y~la:.:..:n=d Standards and Methods of Assuring l-ligh Quality Care The following is a description of the methods that will be used to assure that the medical and remedial care and services are of high quality. 1. The Program will establish specific provider qualifications for each type of provider in regulations and will ensure that only appropriately credentialed providers arc enrolled. 2. The Program will establish and maintain a database of excluded individuals and entities to enhance provider screening responsibilities. The Program will verify and answer questions regarding the database. 3. The Program wi II assure that EPSDT well-child providers are certi lied by the Otftcc of Health Services. 4. Medical care and services shall be provided within the scope ofthc licensure of the provider. 5. Medical care and services not provided by a licensed professional must be recommended or prescribed by a licensed professional. 6. The Program shall ensure the recipient's right to exercise fi·ee choice in the selection of enrolled service providers. 7. The Pr()gram will assure that staff is responsive to recipients· needs and manages or refers complaints. 8. The Program will work closely with the Office of Health Care Quality and the various Professional Licensing Boards to assure quality of medical care standards are met. 9. The Program will procure a Utilization Control Agent who will be responsible for ensuring that medical services arc authorized only when medically necessary. Medical services provided in a hospital on an inpatient basis are authorized only when such services cannot be eOcctivcly provided on an outpatient basis or more effectively and efficiently in a facility of a different type. Medical services provided in a nursing lacility. chronic hospital or in a community-based program are authorized only when an individual is appropriately determined to be medically eligible for those services. TN# ll:Q2 Approval Dat$EP __ ~-- 2011 Supersedes TN # __ Original 1974 Efl'ectivc Date ___ tfLi..2o II

Delete this Page Attachment 3 .1-C Page 2 TN # 11-09 Approval Date -~ EP_ 9_ 2011 Effective Date ..!il!.EO f I Supersedes TN # Original 1974

Delete tlus Page TN # I 1-09 Approval Date S E P Supersedes TN # Original 1974 Attachment 3 .1-C Page 3 9 2011- Effective Date Lf/J j;;. Oil , j.

Delete this Page Attachment 3 .1-C Pagc4 TN # 11-09 Approval DateS EP 9 2011 Effective Date__!!}: };. {) II Supersedes TN # Orig,inn! 1974

Delete this Page Attachment 3.1-C Page 5 TN II 11-09 Approval DateSEP · 9 2011 Effective Date LI-/J };;;Oil Supersedes TN II Original 1974

Attachment 4.19E STATE OF MARYLAND TIMELY CLAIMS PAYMENT Definition of Claim A claim is an invoice for services rendered to a recipient who is receiving benefits through the Medical Assistance Program: UB-04 Form: CMS-1500: TN# 11-09 Institutional inpatient services for Acute Care General, Long Term Care, Hospice, Chronic, Psychiatric and Rehabilitative Facilities all inclusive of Room and Board plus ancillary charges. Institutional outpatient services all inclusive of ancillary charges for a specific date of service. Home Health and Dialysis services- all inclusive for services rendered within the same month for each date of service charged/billed. Line item billing for Professional services rendered on a specific date of service. Approval DateS E P · 9 2011 Effective Date t.fjJ }.J()II Supersedes TN # 81-03 '

Attachment 7.2 A STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF: MARYLAND Title VI of the Civil Rights Act of 1964, Section 60 I states that "no person in the United States shall on the grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." In addition to ensuring compliance with the Civil Rights Act of 1964, Section 60 I, EACU also monitors and ensures compliance with the Hill- Burton Act, Section 504 of the Rehabilitation Act of 1973; the Age Discrimination Act of 1975; and the Omnibus Budget Reconciliation Act of 1981 (Block Grants). The Secretary ofthe Department of Health and Mental Hygiene (DHMH), by law and policy, does not permit discrimination against anyone on the basis of race, color, national origin, age, religion, disability, or sex. This nondiscrimination policy applies to all facilities and programs operated directly by DHMH as well as to providers of health services who receive federal funds under Medicare Part A or Medicaid. Anyone who believes that an act of discrimination has taken place in the areas of delivery of services, treatment procedures, or any other areas as defined in Title VI has the right to file a complaint and to receive a prompt investigation of the allegation(s). All federally funded programs must comply with the requirements and provisions of Title VI of the Civil Rights Act of 1964, Section 60 I. The Equal Access Compliance Unit (EACU) is responsible for ensuring that all individuals receive nondiscriminatory delivery of services from all DHMH facilities and programs operated directly by the Department as well as providers of health services who receive federal funds under Medicare Part A, or Medicaid, regardless of race, color, national origin (including individuals who are Limited English Proficient), age, or disability. EACU monitors and audits DHMH programs operated directly by the Department and other providers of health care operating in the State of Maryland, who are receiving federal funds, to ensure that they do not deny or have the effect of denying qualified clients equal access to federally assisted health care, medical benefits and services for which such persons qualify. Anyone who believes that an act of discrimination has taken place in the areas of delivery of services, treatment procedures, or other covered areas, may file a complaint with EACU or the U.S. Department of Health and Human Services (HHS), Office of Civil Rights. TN# 11-09 Supersedes TN# NEW, Effective Date

ll STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State of: Marvland Attachment 7.2 A Page 1 DHMH POLICY http://www.dhmh.state.rnd.us/oolicies/inoolnthtm OFFICE OF EQUAL OPPORTUNITY PROGRAMS (OEOP)- DHMH POLICY 02.06.04 Effective Date- September 5, 2006 POLICY ON EQUAL EMPLOYMENT OPPORTUNITY (EEO) lsHORTTITLE: EEO POLICY) I. EXECUTIVE SUMMARY Federal statutes and the Maryland Code of Fair Practices prohibit the practice of all forms of discrimination in employment based on non-merit factors. This policy implements the Equal Employment Opportunity program at the Department of Health and Mental Hygiene (DHMH) and ensures compliance with all applicable Federal and State laws and regulations. The policy further prohibits any unit of DHMH from conducting business with firms, institutions. or agencies that engage in workplace discrimination. All units of the Department as well as grant-in-aid programs. health services providers. and DHMH contractors/subcontractors that receive Federal or State funds are covered by this policy. Each Deputy Secretary. Program Director, Facility CEO. Health Officer. unit head or supervisor of one or more employees shall ensure that a review of EEO practices is included as a component of the annual performance evaluation completed for each subordinate supervisor. " The Executive Director. OEOP, or designee has the following responsibilities: to develop, recommend. and monitor DHMH EEO policies and procedures to assure the Department is in compliance with Federal and State laws and regulations. to provide technical assistance to DHMH components in matters regarding EEO practices. where authorized, to act on behalf of the Secretary or Deputy Secretaries of DHMH to carry out the provisions and intent of this policy. to accept timely complaints and conduct on-site reviews, as necessary. to cooperate with Federal and State offices responsible for equal employment opportunity. to prepare an annual EEO report for all DHMH and submit it to the Maryland Commission on Human Relations (MCHR). to monitor all personnel transactions- hiring. promotions, transfers. reassignments, terminations. discipline, etc.- for EEO compliance. All DHMH employees or employment applicants are advised that they may contact OEOP or alternative resources for information or questions regarding EEO, or to file a complaint. II. BACKGROUND DHMH Policy 02.06.04 supersedes and replaces the version dated July 15, 2005. The only significant change, which is administrative in nature, is renaming the Office of Community Relations (OCR) to Office of Equal Opportunity Programs (OEOP). The DHMH policy review process was waived. [ ·--- Departme~.rea tth & Mental Hygiene OFFICE OF REGULATION AND POLICY COORDINATION (ORPC) ·POLICY ADMINISTRATOR 201 West Preston Street· SUite 512- Baltimore Maryland 21201·2301 Phone 410 767·5934 FAX 410 333-7304 TNN;-;-1-09. Approv~ l Duto: ~l*P""'...._g--:'lo1-.=.--Eifec-ti- vc-D-a- te-: --i.t ,.,_...,,...l~} .,..;;:;j -::.-25 :::-:- Ji-:---- Supersedcs No: Original 1974 "t>"E" L 1 ' II

Attachment 7.2 A Page 2 DHMH POLICY 02.06.04 EEO POLICY OFFICE OF EQUAL OPPORTUNITY PROGRAMS Ill. POLICY STATEMENTS A. AUTHORITY Federal and State laws and regulations prohibit the practice of discrimination in employment. This prohibition applies to employment discrimination based on non- merit factors including race, color. national origin, age, religion, sex, disabilities. and any other non-merit factors. Authority for this policy is derived from the following mandates, but other laws and regulations may also apply: 1. Title VII of the Civil Rights Act of 1964. as amended. forbids employment discrimination based on race, color. religion, sex, and national origin; 2. The Age Discrimination in Employment Act of 1967 (ADEA) makes discrimination against employees for reasons of age illegal; 3. Article 498, Annotated Code of Maryland and the Rehabilitation Act of 1973 prohibit discrimination against persons with a disability. 4. The Equal Pay Act of 1963 prohibits discrimination in wages based on sex. 5. Title I and V of the Americans With Disabilities Act of 1990 prohibits discrimination based upon a disability. 6. The Governor's Executive Order 01.01 .1995.19 -Code of Fair Practices prohibits employment discrimination in State Government including discrimination based on sexual orientation. B. SCOPE 1. This policy applies to all DHMH programs, facilities, independent units such as Boards and Commissions, Local Health Departments. grant-in-aid programs, health services providers, and DHMH contractors/subcontractors receiving Federal or State funds. 2. No component of DHMH shall conduct business with firms, Institutions, service providers, or agencies that engage in unlawful discrimination. C. ROLES AND RESPONSIBILITY 1. Each Deputy Secretary shall ensure that equal opportunity exists in all employment practices within the scope of his or her responsibility. 2. Each Deputy Secretary, Program Director, Facility CEO, Health Officer, unit head or supervisor of one or more employees shall ensure that a review of EEO practices is a component of the annual performance evaluation completed for each subordinate supervisor. 3. Each Program Director, Facility CEO, Health Officer, and unit head or supervisor of one or more employees shall follow the guidelines of this policy within his or her area of responsibility. 4. The Executive Director, OEOP, is designated by the Secretary, DHMH, to have oversight responsibility for the following: PAGE20F4 Dhmh EEO Policy 02.06.04, effective September 5. 2005 supersedes version dated July 15. 2005. j TN No: 11-09 Approval Dato· (' LP-__fl_~~l_:_ Effective Date: il-/ J, ~ 0 I J Supersedes No· Original 1974 O'C - · ;:~ -Z.Vf f

Attachment 7.2 A Page 3 DHMH POLICY 02.06.04 EEO POLICY OFFICE OF EQUAL OPPORTUNITY PROGRAMS a. Develop, recommend, and monitor policies and procedures necessary for DHMH to be EEO compliant with Federal and State laws and regulations. b. Provide technical assistance and advice on EEO practices to all DHMH components. c. Monitor all personnel transactions- hiring, promotions, transfers, reassignments, terminations, discipline, etc. for EEO compliance. d. Where authorized. act for the Secretary or Deputy Secretary in carrying out the provisions of this policy. e. Accept timely complaints and conduct on-site reviews, as necessary. f. Work in concert with the Maryland Commission on Human Relations (MCHR) and the Federal Equal Employment Opportunity Commission (EEOC) in the investigation of alleged discrimination. g. Prepare and submit relevant reports to the Secretary and appropriate Federal and State agencies. D. RESOURCES FOR OBTAINING SERVICE 1. DHMH OFFICE OF EQUAL OPPORTUNITY PROGRAMS-EMPLOYMENT EQUITY UNIT The OEOP Employment Equity Unit attempts to quickly resolve employment discrimination disputes through mediation, investigation, and training; and to maintain a discrimination-free work environment for all employees within DHMH regardless of race, color, sex, religion, national origin, age, disability, or sexual orientation. a. If you believe you have been discriminated against at DHMH, you may file a complaint with the Employment Equity Unit. Complaints must be filed within 30 days of the alleged discriminatory practice or act. Please call 41 0-767-6600 to schedule an appointment. All matters discussed in office will be kept confidential, except where a complaint is filed and served on management. If you decide to submit a written complaint after discussion with the Employment Equity Unit staff, they will assist you in completing the Fair Employment Practices Complaint Form. b. You may choose instead to file a complaint with the Statewide EEO Coordinator at the Department of Budget and Management. the Maryland Commission on Human Relations, or the US Equal Employment Opportunity Commission. Please note that the filing deadlines vary. hllp.//www.dhmt1.slate.md.us/ocr/eeu/eeuhome.htm 2. DBM OFFICE OF THE STATEWIDE EEO COORDINATOR The Office of the Statewide EEO Coordinator enforces the Governor's Code of Fair Employment Practices, which ensures equal employment opportunity for all State employees and applicants for State employment. and provides a means for resolution of employment discrimination complaints. DHMH employees may wish to file directly with this office. Complaints must be filed within 30 days of the alleged discriminatory practice or act. PAGE3oF4 Dhmh EEO Policy 02.06.04. effective September 5. 2005 supersedes version dated July 15. 2005. J TN No: 11-09 Approval Date: "S£p-- ~' 9 2011 Effective Date: _ __ .!t}._!_, a tJ// Supersedes No: Original 1974

Attachment 7.2 A Page 4 DHMH POLICY 02.06.04 EEO POLICY OFFICE OF EQUAL OPPORTUNITY PROGRAMS DBM Office of the Statewide EEO Coordinator 301 West Preston Street - Room 608 Baltimore, Maryland 21201 410-767-3800 or 1-800-411-5123 http://www.dbm.marvland.gov/ 3. THE MARYLAND COMMISSION ON HUMAN RELATIONS (MCHR) Within 180 days of the employment decision you believe to have been discriminatory, call the MCHR at 410-767-8600 to set up an appointment or begin the process of filing a charge of discrimination. Maryland Commission on Human Relations 6 St. Paul Street, 9th Floor, Baltimore, MD 21201 410 767-8600 http://www.mchr.state.md.us/ 4. US EQUAL EMPLOYMENT OPPORTUNITY COMMISSION (EEOC) EEOC is responsible for employment discrimination on a Federal level. The agency is charged with enforcing Title VII of the Civil Rights Act of 1964, as amended, the Equal Pay Act (EPA), the Americans with Disabilities Act (ADA) of 1990 and the 1967 Age Discrimination in Employment Act (ADEA). Complaints must be filed within 300 days of the alleged discriminatory practice or act, or in some cases when you become aware of the alleged discriminatory practice or act. Equal Employment Opportunity Commission Baltimore District Office - 1 0 South Howard Street, 3rd Floor Baltimore, Maryland 21201 410-962-3932 http://www.eeoc.gov/ IV. REFERENCES * * * * The Equal Pay Act of 1963, http://www.eeoc.gov/epa/ Title VII, The Civil Rights Act of 1964, as amended. http://www.eeoc.gov/policy/vii.html The Age Discrimination in Employment Act of 1967 http://www.eeoc.gov/policy/adea.html Titles I and V, The Americans with Disabilities Act of 1990 http://www.eeoc.gov/abouteeo/overview laws.html * Governor's Executive Order 01 .01.1995.19- Code of Fair Practices, 1995 http://www.dbm.marvland.gov/dbm publishing/public content/dbm taxonomy/emp loyee services/equal employment opportunity/codeoffairpractices 1995. htm APPROVED: /S/ Signature on File S. Anthony McCann, Secretary September 5, 2006 Effective Date Dhmh EEO Policy 02.06.04, effective September 5, 2005 supersedes version dated July 15, 2005. PAGE 4 OF 4 TN No: 11-09 Approval Date: ·sfp .. ~ _' 9 ~ 2011 Effective Date: A- fl(l L I 1 d-O II Supersedes No: NEW ~

LOF FOR: E TER FOR MEDI ARE & MEDI AID SERVI E TO: R Gl NAL ADMINISTRAT R CENT RS FOR MEDICAR • & MEDICAID SERVICES D PARTMENTOF H ALTII AND IIUMAN SERVICE 5. TYPE TATE PLAN COMPLETE BL 6. FEDERAL T A TUTEIREG 15. OAT BMITIED: T e Director u an J. Tucker, ~xcc uti ve Director OH - D MH 201 W. Pre ton t.. 1 1 flo r Baltimore, MD 2 1201 FOR REGIONAL OFFICE USE 0 LV 17. DATE RECEIVED: 1 18. DATE APPROVED: .::ru IJ~ 1'7, 01.0 r 1 . SEP -_ 9 2011 19. EFFECTIVE DATE OF APPROVED MATERIAL: 2 NA F ,,....,,,..,,_..,.. l}fJI?tL I Ol.0/1 21. TYPED NAME: jl-fS/h)C,/S /J1e btlt../L)V 23. REMARKS: C:.illttJtJB 'fO IT~H~ ~gl q I ~~-~.b JD tuldlC tHJf-() E" //() !fCC012.D,fJ<lC£ td t'llf. -nf-E: fi~V~ 6>r /1t{-l.<f~ S'Tf7t 1-/oft-TE-/ ~tCt,tfLS~ F RM II A-179 (07-92)

DEP-ARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS for MEDICARE. MEDICAID SEIMCES Region ill/Division of Medicaid and Children's Health Operations 'JUL 2 6 2011 I Charles J. Milligan Jr., Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Room 525 Baltimore, MD 21201 Dear Mr. Milligan: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 11-10. This SPA, in accordance with Section 2302 of the Affordable Care Act, makes hospice services available to children eligible for Medicaid and children eligible for the Medicaid-expansion Children's Health Insurance Program without forgoing any other service to which the child is entitled under Medicaid for treatment of the terminal condition. The effective date for this amendment is April 1, 2011. The signed CMS-179 form and the approved State Plan page are enclosed. If you have questions about this SPA, please contact Rosemary Field of my staff at (215) 861- 4278. Enclosure cc: Rebecca Hyman- MD DHMH Sincerely, -~ ~~Q~ Ted Gallagher ::::::S. 1 Associate Regional Administrator

Revision: HCF A-PM-86-20 (BERC) SEPTEMBER 1986 ATIACHMENT 3.1-A Page 7 State/Territory---'M~a~ry'-'-l==an""'d=------------ AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THECA TEGORICALL Y NEEDY 15. a. Intermediate care facility services (other than such services in an institution for mental diseases) for persons determined in accordance with section 1902(a)(31 )(A) of the Act, to be in need of such care. [X] Provided [] No limitations [X] With limitations* [ ] Not Provided: b. Including such services in a public institution (or distinct part thereof) for the mentally retarded or persons with related conditions. [X] Provided [X] No limitations [ ] With limitations* []Not Provided: 16. Inpatient psychiatric facility services for individuals under 22 years of age. [X] Provided [] No limitations [X] With limitations* [ ] Not Provided: 17. Nurse-midwife services [X] Provided [] No limitations [X] With limitations* [ ] Not Provided: 18. Hospice care (in accordance with section 1905(o) of the Act). [X] Provided [ ] No limitations [X] [X] With limitations* [ ] Not Provided: *Description provided on attachment TN # 11-10 Supersedes TN # 90-06 Provided in accordance with section 2302 of the Affordable Care Act

FI::.DERAL REG LATI Cll TIOt : P 11 -10 Attachment 2.2 41 FR r. IO Attachment 1.6A 42 FR Part 43:, cction -1 5. I 0 nnd 'ul pnn G&ll AT-71!-90. A -80-6 AT-80-34, 1902(1) und (n)Clrthc ct, P.L.99-509( ccs. IJ,IOI and9402),1902(1 and n)and 1920ofthcAct, P.L. 99-509 ( c s. 9401. '>-102. and 9407) ttachment 3. 1 Patt 400, 'ubpart 13 and I 1JQ_(c (5 . 1905(a}( 18) through 20). nnd 1920 of the Act. P.L. 99-272 ( cc t ion~ 950 I. ·os and 9526) and I Q .2(a}. I '-l02(a (47). 1902 (c (7) lhr ugh 9 , and 1920 of the Act, P.L. 99-509 ( ccti n 940 1 d). 9403.94 through 9-108) and P.L. 99-514 ( e tion 1985{cX3) Attachment •. I B 41 I·R Part 440. ubpart B. •L U-R -l<l1 .15. AT· 78-90. I· 0-3<1 Attachment 3.1 42 l'R 431.5'. AT-78-90 Allachment 3. I I· I ?05(n)(_4) und 1930 or the A 1, Jl. L. I 0 1-508 (Sect ion 712 >BRA 90) Attachment 4.18A 447.51 through 447.58 Allachment4.18 4 7.51 through 447. 8 uachmem4.18-F 447.50-447.-9 Altachmcm 4. 19 A&B a) 42 FR 44 7.252. ·I 1 f·R 4-1964, 8 FR 56046. 50 rR _J009. I 02(e (7) of the ct, P.L. 99-.0 ( cctiun 9-IOI(d)J (b) 42 FR447.201.4.2 FR4<17.302. AT-78-90. T-80<'4, 1903 u) l}and(n)and 1920 of the Act. P.l .. 99-509 (Section C).JOJ. 9406 and 9407). 52 FR 28648 Attachment 4.16 •12 ' FR 4 1.615 c) AT-78-90 nachmcnt •U D (d)<l_ FR 447.25-. 47 FR 4796-l, 48 FR ~6046. 42 CFR 447.2 0. 47 FR 31518. -2FR2141 uachment4.22A .tH3 .1.,7( n). SO ·R46652. 55 rR 1423 Attachment 4.22B (b) 433. 138(f). :2 FR 5967. t1JJ.138(g)( I )(ii) and (2)(i i). 52 FR 5967. 4 '3.133(g)(3 (i) ond (iii . 52 FR 5967.433. 1 8(h)(4)(i) through iii). · ~ FR 5fl67 Auachment 4.22 cction 1906 of the Act ttnchmcnt4.26 1<>27 )42CFR456.700, J927(g) I)( ). J927(g( l)(a) 2 FR456.70"(b)and 456.709(b . 1927(g.l IXB) 2 FR 5670'(d and(f), JQ2 (g) l)tf) 2 'FR<I56.703(b. 1927(g)(2) ) 2 FR 456.705(b). IC)17(g)(_J( )(i) 42 O:R •1.56.70. b), l9_7(g 2 ( (i) - 'FR 456.70 (b). (1)-(7). 1927(g (2)(1\)(ii) 2 C rR 456.705( ) and (d). 19-7(g)(2) B' 4_ CFR 456.70 , ). 1927Cg (2)(C) 42 CFR 456 709(b). 1927(g)(::!l(D 42 CFR 456.711, 1927 (g)('')( 42 FR 456.7 I 6(a), 19 .. 7 (g)(J)(B) 42CFR456.7 1 (A)and(B,I92 (g)(3J )4_ FR4 .716(d 1927(g(3)( )42 rR4 6.71 1(aHd). 1927(g)(3 (D) 42 fR456.712(A)and(0), 1927(1> 1)42 FR456.722.1927(g -)(A (i) 42 CFR 456.705(b), 1927U)(_) 4_ CFR 456.70 c) Attachment 4.'2A (,) 435.940 through 4~5.960. 5- FR 5967 Anachmem 4.3 A (a) 1902(a)(4 8) of the Act. f>.L. 99-570 (Section II oo·). P.L. I 00-93 (Section 6(a )) Attachment4 . .?5A (, 191 9(b)(l)and 2)ofthc ct. P .. I 0-103 e tion4-12(a)) Attachment 4.35 0 (b) ·arne as above AUachmt•nt 4.44 St'CIIOil 190- (a)(80) or the Act, r.l .. 111 - 148 ( 'cction 6 05)

Drl'·\lthu:, T Oi· lll:i\ I.TII I\ , D I lUMAN SERVILT '\ JIJ.,\1 111 CARF Fl At-!CING AD ·II JSl RA liON TRA MITTAL AND NOTICE OF APPROVAL OF T TE PLAN MAT • RIAL FOR: CENTERS FOR MEDI ARE & MF.DI AID ERVI ES TO: REGIONAL ADMI I TRATOR CENTERS FOR •1 ·DI ARE & 1EDI AID ERVICE DEPARTMENT OF IIEALTII A D II IAN 'ER ICE 5. TYPE OF PLAN MATERI L (Citeck One): 42 CFR 447.205: , cction 230_ ofthe AfTordablc arc Act Attachment 3.1-A Page 7 I. TRANSMITTAL UMBER: 11-1 0 FORM APPROVED 0 111 0 . 0938-01 93 2. STATE Maryland I 0. UBJECT OF AMENDMENT: To document laryland 's accordance with Act- concurrent hospice care for children in Medicaid and HIP. eclion 2302 of the Affordable Care II . GOVERNOR .. REV I \V r heck One): 0 GO ERNOR'S OFFI E REPORT D NO OMMF. T 0 COM ME TS OF GOVERNOR"S OFFIC - E CLOSED 0NOREPLYRECEIVEDWITH IN45DAY OFS BM ITT/\L . F STATE AGENCY OFFICIAL: 14. TITLE: Deputy ecretary for Health are Financing 17. DATE RECEIVED: J cJtf/1?:' !7 1 d-r} I I 19. EFFECTIVE DATE OF AfPROV -D MATERIAL: IJ-f/ ~ J L I .;;;-tJ I I 23. REMARKS: [8J 0 HER, AS . PE IFI 1): usan .1. Tucker. Executive Director Office of Health Services 16. RCT H ' ro: Susan J. Tucker, Executive Director OHS - DHMH 20 I \V. Pre ·ton Sl.. 1·' n or Baltimor, MD 2120 1 JUL 2 6 2011 "ITEI-1 :t~:-q ~ (!.o !l fl f:-?!..P tJAJ tJ1 hiJ t= ; IJ 1}-e.c o f2J) ?foUe.£ W /Tr/ /110 CJpP,c 1/tt- / 11/.i :77lU LJI 0 I() · FORM HCFA-1 79 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS for MEDICARE .J MEDICAID SE/MCES Region IIJfDivision of Medicaid and Children's Health Operations JAN 5 2012 Charles J. Milligan, Jr. Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Suite 525 Baltimore, MD 21201 Dear Mr. Milligan: We have reviewed the Maryland State Plan Amendment (SPA) 11-16, which updates dispensing fees to pharmacy providers to reflect current rates. The SPA reduces dispensing fees by five percent. In addition, this amendment adds language regarding coverage of smoking cessation products for pregnant women to the pharmacy section of the State Plan. The pharmacy section has also been reformatted for improved organization and clarity. The Pharmacy Team at the Division of Pharmacy at Centers for Medicare & Medicaid Services (CMS) Headquarters approved this SPA on December 22,2011. The effective date ofthe SPA is July 1, 2011 . Enclosed are the approved State Plan pages and the signed CMS-179 form. If you have any questions regarding this amendment, please contact Rosemary Feild at (215) 861-4278, or via e-mail at rosemary.feild@cms.hhs.gov. Enclosures cc: T. Simananda - CMCS Do vou know someone It' flO has !wen denied 11/edicol in.wronct: becmtsl! 1l a pre-existing condition:' ffso. 1hev muj: he eligihlefor 1/ze 1/Cl l' Pre-Exist inx Condition lnsunm c ·e Plan. Call toll.fi'ee 1-866- 717-58:!6 rTTY 1- 866-56 1-1 (j{)-J J or Fisit www.pcip. gov ond dick on ... Find Your State " to learn more.

•••• Attachment 3.1 A Page 25 STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND 12. A. Prescribed Drugs A. The following are not covered: 1. Non-legend drugs other than; insulin, Schedule V cough preparations, family planning products, enteric coated aspirin used in the treatment of arthritic conditions and any other cost effective medications as specified by the · Program. 2. Any original prescription: a) For a controlled substance dispensed more than 30 days after the prescribing date; and b) For a non-controlled substance dispensed more than 120 days after the prescribing date. 3. Drugs supplied to hospital inpatients. 4. Experimental or investigational drugs. 5. Oral drugs or injections for central nervous system stimulants and anorectic agents when used for weight control. 6. Drug products for which Federal Financial Participation is prohibited pursuant to 42 CFR441.25. 7. Ovulation stimulants for oral or parenteral administration. 8. Any Part D drug for individuals who are eligible for Medicare Part D benefits. 9. Drug products marketed by a manufacturer or distributor who has not entered into a rebate agreement with the Secretary of the Department of Health and Human Services as described in Section 1903 of the Social Security Act or a manufacturer who has not signed a rebate agreement with the State of Maryland prior to April 1, 1991, except Coverage will be allowed for single source drugs and innovator multiple source drugs if: a) The State has made a determination that the drug is essential to the health of the beneficiaries; b) The drug has been rated as 1-A by the Food Drug Administration (FDA); and c) The authorized prescriber has obtained approval for use of the drug in accordance with the States' prior authorization program as described in D of this Section (Preauthorization Requirements) of the Secretary has reviewed and approved the State's detenninations. 10. No covered drug shall be reimbursed if: TN# 11-16 a) Federal financial participation from the Centers for Medicare and Medicaid Services is not available for the drug; or b) Prior authorization was required for the drug, but was not obtained. Supersedes TN # 03-07 Approval Date [Jt£JJ 2 2 2911 Effective Date .:TtiL'f 11 ;( 0 If

. / . . . Attachment 3.1 A Page 25-1 B. Following are covered: TN#II-16 Smoking Cessation Products-The Medicaid agency will provide coverage of prescription and over-the counter (OTC) smoking/tobacco cessation covered outpatient drugs for pregnant women as recommended in "Treating Tobacco Use and Dependence -2008 Update: A Clinical Practice Guideline" published by the Public Health Service in May 2008 or any . subsequent modification of such guideline. Supersedes TN # 03-07 Approval Date ·DEG 2 2 2011 Effective Date I u L '( I J ;) D II

... State: Marvland Attachment 3.1 A Page 25-2 MEDICAID PROGRAM: REQUIREMENTS RELATING TO PAYMENT FOR COVERED OUTPATIENT DRUGS FOR THE CATEGORICALLY NEEDY 12. A. Prescribed Drugs 1927(d)(2) and 1935(d)(2) 1. The Medicaid agency provides coverage for the following excluded or otherwise restricted drugs or classes of drugs, or their medical uses to all Medicaid recipients, including full benefit dual eligible beneficiaries under the Medicare Prescription Drug Benefit -Part D. The following excluded drugs are covered: ~ (a) Agents when used for anorexia, weight loss, weight gain (Only legend products that are not CNS stimulants are covered eg. Xenical) D (b) Agents when used to promote fertility D (c) Agents when used for cosmetic purposes or hair growth ~ (d) Agents when used for the symptomatic relief cough and colds (Only legend products are covered) D Prescription vitamins and mineral products, except prenatal vitamins and fluoride Nonprescription drugs (enteric coated aspirin and OTC's on the preferred drug list are covered) (g) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee (see specific drug categories below) ~ (h) Barbiturates G (i) Benzodiazepines (The Medicaid agency lists specific category of drugs below) No excluded drugs are covered. TN#ll-16 Supersedes TN # 93-04 Approval Date [)EQ 2 2 2911 Effective Date :::TU'-tj 11 ;l Oil

Attachment 3.1 A Page 25-3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Agency ---'M=ary~lan=d _____ _ MEDICAID PROGRAM: REQUIREMENTS RELATING TO PAYMENT FOR COVERED OUTPATIENT DRUGS FOR THE CATEGORICALLY NEEDY Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full- benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B. TN#ll-16 Supersedes TN #New Approval Date .I)Ef' 2 2 2011 Effective Date 7 {I L'f I 1 ~ tJ I I

Attachment 3.1A Page26 A. Rebates TN# 11-16 1. The state is in compliance with section 1927 of the Social Security Act. The state will cover drugs of federal rebate participating manufacturers. The state is in compliance with reporting requirements for utilization and restrictions to coverage. Phannaceutical manufacturers can audit utilization data. The unit rebate amount is confidential and cannot be disclosed for purposes other than rebate invoicing and verification. 2. The state will be negotiating supplemental rebates in addition to the federal rebates provided for in Title XIX. Rebate agreements between the state and a pharmaceutical manufacturer will be separate from the federal rebates. 3. A rebate agreement between the state and a drug manufacturer for drugs provided to Medicaid recipients, submitted to CMS on July 21, 2003 and entitled "State of Maryland Department of Health and Mental Hygiene Supplemental Rebate Agreement" has been authorized by CMS. 4. Supplemental rebates received by the State in excess of those required under the national drug .rebate agreement will be shared with the Federal government on the same percentage basis as applied under the national rebate agreement. 5. All drugs covered by the program, irrespective of a prior authorization requirement, will comply with provisions of the national drug rebate agreement. 6. The State is establishing a preferred drug list with prior authorization for drugs not included on the preferred drug list pursuant to 42 U.S.C. section 1396r-8. Prior authorization will be provided with a 24-hour tum-around from receipt of request and a 72-hour supply of drugs in emergency situations. 7. Prior authorization will be established for certain drug classes, particular drugs or medically accepted indication for uses and doses in compliance with federal law. 8. The State will appoint a Phannaceutical and Therapeutic Committee or utilize the drug utilization review committee in accordance with federal law. 9. CMS has authorized the State of Maryland to enter into The Optimal PDL Solution (TOPS$®).· This Supplemental Drug Rebate Agreement was submitted to CMS on December 7, 2004 and has been authorized byCMS. Supersedes TN # 03-07 Approval Date [)ElJ· 2 2 2911 Effective Date 17f/Uj I 1 d 0 I I

Attachm~nt 3.1 A Page 26-1 DELETE THIS PAGE TN#ll-16 Supersedes TN # 03-07 Approvalbl\te.IJE(J· 2 2 2011 EffectiveDate ifttLLf 11 ~ {)/!

TN# 11-16 Supersedes TN # 03-07 Reserve for Future Use Attachment 3.1 A Page 27 Approval Date .IJEe· 2 2 2011 Effective Date \Ill L <f I 1 d () If

TN# 11-16 Supersedes TN# 05-13 Delete this Page Attachment 3.1A Page 27A Approval Date IJEi· 2 2 2911 Effective Date gULCf 11 ;;? 0 J I

TN# 11-16 Supersedes TN# 04-01 DELETE THIS PAGE Attachment 3.1 A Page 27A-1 Approval Date & 2 2 2011Effective Date V:t1Lcf 11 ,;;?. 0 I I

TN#li-16 Supersedes TN# 04-01 DELETE THIS PAGE Attaclunent 3.1 A Page27A-2 Approval Date UIEi· 2 2 2911 Effective Date iTVL'f 11 d. 6 I I

TN# 11-16 Supersedes TN # 06-06 DELETE THIS PAGE Attachment 3.1 A Page 27A-3 Approval Date liEf); 2 2 201t Effective Date \/ U L'f I 1 ;;< () I I

TN# 11-16 Supersedes TN # 06-06 DELETE TillS PAGE Attachment 3.1 A Page 27A-4 Approval Date ·lEi· 2 2 2011 Effective Date . r:/CIL-lj I 1 OUJ I I

TN# 11-16 Supersedes TN# 06-06 DELETE THIS PAGE Attachment 3.1A Page 27A-5 Approval Date -fJEe-2 2 20·11 Effective Date \!VL-tj 11 ;;;( (} J I

TN# ll-16 Supersedes TN # 06-06 DELETE THIS PAGE Attachment 3.1 A Page 27A-6 Approval Date & 2 2 tft11 Effective Date \Tf.IL l( 11 ;(_ t!J I I

Attachment 4.198 Page 35 Payment for drugs, effective July 1, 2011 shall be as follows: A. Determination of allowable cost; TN#ll-16 1. For covered multiple source legend drugs, including Schedule V cough preparations, listed on the Program's Interchangeable Drug List, allowable cost shall be the lowest of: a) The Interchangeable Drug Cost (IDC) which is the maximum amount the Program will reimburse for selected, approved interchangeable multiple source drugs determined by any of the following: (i) Lowest estimated acquisition cost of the generically equivalent products available in the State; (ii) Price obtained by: aa. Ascertaining the lowest cost from among the approved interchangeable multiple source products from each wholesaler that the Program has current and accurate pricing information, and bb. Selecting as the IDC the highest of costs ascertained in (a) above; or (iii) Price from a commercial generic pricing source. NOTE: Maximum allowable costs will be reviewed and updated: aa. At least once every year, bb. Whenever there is an emergency recall by the Food and Drug Administration, or cc. Temporarily, if there is an acute shortage of supply from available sources. b) The Estimated Acquisition Cost (EAC) which is the lowest price of a drug product as determined by the following criteria: (i) Wholesale Acquisition cost (WAC) plus eight percent; (ii) Direct price plus eight percent; (iii) Average Wholesale Price (A WP) less twelve percent c) Federal Generic Upper Limit (FGUL) which is the upper limit of . payment for a multiple source drug for which a specific maximum allowable cost has been established by the Center for Medicare and Medicaid Services (CMS) of the Department of Health and Human Services; 2. For all other covered legend drugs, including brand name drugs for which the prescription requires the brand name drug to be dispensed, the allowable cost shall be the EAC established by the Department 3. For covered over-the-counter insulin the allowable cost shall be based on the A WP of the item. 4. For covered over the counter enteric coated aspirin the allowable cost shall be the lowest of: a) IDC; b) EAC; or c) FGUL Supersedes TN # NEW Approval Date 9Ee· 2 2 2011 Effective Date VU L '1 I 1 ;( {) I I

Attachment 4.19B Page 35A B. Payment for covered services to a phannacy 1. Payment for legend drugs, Schedule V cough preparations, and enteric coated aspirin will be the lower of: a) The Provider's usual and customary charges, less any applicable co-payment; or b) The total of: (i) The allowable cost of the item; (ii) Plus the applicable professional fee; (iii) Less any applicable co-payment. 2. Payment for over-the-counter drugs other than enteric coated aspirin shall be the lowest of: a) The provider's charge according to (B)(l)(a), above; or b) The allowable cost plus 50 percent, less any applicable co- payment; or c) The allowable cost of the item plus a professional fee. 3. The Department may pay providers using an approved unit dose system on the basis of a daily or monthly dispensing fee per nursing home resident. The value of these fees may not be higher than the phannacists' usual and customary charge to the non-Medicaid patients for similar services. Payments to nursing facilities will not exceed, in the aggregate, the FGUL. C. The professional fee is a variable fee based on the type of prescription and is $2.56 for brand name drugs not on the preferred drug list and $3.51 for generic drugs and for drugs on the preferred drug list, except for prescriptions for compounded intravenous therapy and prescriptions for recipients residing in nursing homes. TN# 11-16 1. For compounded prescriptions for intravenous therapy the professional fee is the lower of i. $6.89 per day of therapy; and ii. $6.89 per unit of therapy compounded. 2. For prescriptions for recipients residing in nursing facilities, the professional fee is $3.51 for brand name drugs not on the preferred drug list and $4.46 for generic drugs and for drugs on the preferred drug list. Approval Date. Supersedes TN # NEW 0 DEe 22 2011 Effective Date v C/ L V I 1 ;;( (J I I

Attachment 4.19B Page 35B D. Payment for covered services to authorized prescribers shall be made as follows: 1. The Program shall reimburse an authorized prescriber for covered drugs dispensed at the lower of: a) The authorized prescriber's actual acquisition cost, less any applicable co-payment; or b) The allowable cost of the item, less any applicable copayment E. Reimbursement to an authorized prescriber for dispensing covered drugs to Medicaid recipients will be on the same basis as reimbursement to a registered pharmacist, if: 1. The authorized prescriber dispenses drugs on a regular basis in the office; 2. The authorized prescriber's office is not located within a 10 mile radius of a Medicaid participating pharmacy; and 3. The Program, after a consultation with the Board of Pharmacy, has verified that the authorized prescriber is dispensing drugs in accordance with accepted pharmacy standards. F. Payment will be made only for drugs supplied by manufacturers that have a signed national agreement or an existing approved agreement with the State, as set forth in Attachment 3.1A. G. The State will not pay for: TN# 11-16 1. Prescribed drugs as described in Attachment 3.1A, Prescribed Drugs, Limitations. 2. Products that are not medically necessary or life sustaining or are essentially cosmetic in nature. Supersedes TN # NEW Approval Date DEG' 2 2 2tJl'1 Effective Date .:TlrLCf I 1 ;;uJIJ

TN# 11-16 Supersedes TN # 96-02 RESERVE THIS PAGE Attachment 4.19A&B Page 5 Approval Date Q.EG' 2 2 2011 Effective Date ctz1( lf I 1 ;z_ e! I 1

TN# 11-16 Supersedes TN # 03-07 DELETE THIS PAGE Attachment 4.19A&B Page Sa Approval Date BEe: 2 2 2011 Effective Date vilt..'j l1 2 eJ/1

TN#ll-16 Supersedes TN # 05-03 RESERVE TillS PAGE Attachment 4.19A&B Page 6 Approval Da~e Ofe 2 2 29111 Effective Date 1/&u/ I 1 ;J..fi 1/

TN# 11-16 Supersedes TN # 05-03 DELETE THIS PAGE Attachment 4.19A&B Page 6a Approval Date DE6 2 2 20:11 Effective Date vC/ L i I, 2 ()I I

TN# 11-16 Supersedes TN# 91-21 RESERVE THIS PAGE Attachment 4.19A&B Page7 Approval Date DES, 2 2 2911 Effective Date J L/ (._ 1 11 J_1J I I

TN# 11-16 Supersedes TN # 05-13 DELETE TillS PAGE Attachment 4.19 A&B Page 7A Approval Date QE·G 2 2 2n11 Effective Date lTUUf 11 :;2 (}/I

TN# 11-16 Supersedes TN # 05-13 DELETE TillS PAGE Attachment 4.19A&B Page 7B Approval Date BEO 2 J 20lJ Effective Date ::; fd( y 11 ;J. 0 I 1

TN # l.l:.lQ Supersedes TN # 05-13 Delete this Page Attachment 4.19A&B Page 8 Approval Date DEC, 2 2 20. 11 Effective Date ~liLY 11 M j,l

m 1'1\I<T\tl vr or 111-.t\Ufi.·\Nilllt ;MAN ~rttvrns 1_~ :;:\!JI !.~~~~~ . I 'JN~~I:'!!i _,\!~~~~IS_lli_i~j"~( .l~-- .......... .. . . - ·· TRANSMJTT ALAND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR ~U-:t>ICARE & MEUICAIU SI-:RVICES · Yo: . Ri~ui<i~"A~ ~I\f>~uNtsTRATOR CENTEitS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF IIEALTU AND HUMAN SERVICES 1. TRANSMITfAL NIJMBER: I 1-16 FOR\t AI'I'R( 1\'Hl •. ·- ·- · (ll\~-~·111'1~ - 2. STATE Maryland ~~~~~~~==~~~~~~~~----­ J. I•ROGRAM IOENTIFlCATION: TITLE XIX OF HIE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE OATE July I. 2011 - -----·------------ ---- ----- 1\I:W SlATE I'I.AN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 18} AMENDMENT COMPLETE BLOCKS 6 THRU 10 If TillS IS AN AMENDMENT tSe >nrar,• Tr,m.,millttl or f!(l<'il amc:nJmenfJ 6. FEDi ~RAI~ STATUTE.iRf.:(iul.ATiON CITATION: 7. FEDERAL BUDGET IMPACT: K. PAGE NUMIJER OF ntE llLAN SECTION OR ATTACIIMENT: ~. lApp . 25. 25·1. 2~-2. 2CJ, :!6-1. 27. 27A •-•) .-UCIA&B Pfl· !i through 'HQ' c.J..l..ii:Jl.t/.fll(f? 4.1QIJ pp. 35, 35A. 3SR (N'E\ti) .3.\A W· ~11 '~ (N~\ a.FFY 2011: 8750 h. FFY ' 7 9. PAGE NUMBER OF TI-lE SUI•ERSEDED PLAN SECTION OR ATTACI-IMENT ff/Applicah/c:J: .l.IA l'll25. :!~- I. 26. 2f>·l. 27 (03·1171 J.IA l'll:!S-2 t•>.l..(l-11 '0) \ J . tArp:!7At~ U· "f!;,..J :1.1 ,\ JIJI 27 r\-1 - 27 A-6 (l>d.:t..:) ~ 1'1.11. - J .I.JIIM.H I'P· S 191':~-21. (t(05-0J). 7 191·211 <._,ltt~~ 4.1'M&IJ VI'· 5:L. (•a. 7.~ Cllch:tcl --·v 0 • 10. SUBJECT OF AMENDMENT: To update the new pwl'eliliioRaljees to the phamutcy providers to retlect current ral~s . JjfS{J(?).JS tN (r II. GOVERNOR'S REVIEW tCIIt!,·k 01it>1: 0 OOVERNOR'S OFFI('E REPORTEJ.> NO COMMENT 0 COMMENTS <W OOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITI-fiN 4!i DAYS OF SLIHMI'J"l'At -12 .-Siti~~,.~T!l!ttv)~~=~·y· OF~fiAl~ =·~-~~~~~-- u. I'YI'W NAME: Charles J. Milligan • .lr. - ~ - - - --- · ----- - - .-- ·· · ----- ._ .. ,. ____ ·--·····- _ .. __ ._ ____ ·-· ·- 14. TITLE: Secretary. Departmcnl of Health & Mental II •ienc t!i. nATE suBMITTED: ql 'Zot 1 z.o 1 1 ~ OTUER. AS SPECIFIED: Susan J. Tucker. Executive Director Oflice of Heuhh Services 16. RETURN TO: Susan J. Tucker. Executive Director OHS- 01-JMII 20 I W. Preston St.. I'' fluor Baltimore. MD 21201 FOR REGIONAL OFFICE liSE ONLY 17. DATE RECElVED: q /JtJ I dO (I Ill. DATE APPROVED: 21 . TYPED NAME: Fl?. FORM llCFA· I79 107-921

Di'.P ARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS for MEDICARE & MEDICAID SERVICES Region IIVOivision of Medicaid and Children's Health Operations SWIFT #101420114049 OEC -16 2011 Charles J. Milligan Jr., Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Room 525 Baltimore, MD 2120 I Dear Mr. Milligan: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 11-20. This SPA, in accordance with Section 113 of the Children's Health Insurance Program Reauthorization Act (CHIPRA), eliminates the previous requirements for deemed newborn Medicaid eligibility that the newborn must come home from the hospital to live with the mother, remain a member of the mother's household, and that the mother remain eligible for Medicaid, or would remain eligible if still pregnant. By virtue ofthis change, all newborns born to women covered by Medicaid for the child's birth, including coverage of an alien for labor and delivery as emergency medical services, are now covered as mandatory categorically needy. The effective date for this amendment is October I, 2011. The signed CMS-179 form and the approved State Plan pages are enclosed. If you have questions about this SPA, please contact Rosemary Feild at (215) 861-4278. Sincerely, 'All~ tl...Jrancis McCullough '"'0 -Acting Associate Regional Administrator Enclosure Do you knol l' .\U/JI<'Oih' li ho hu.1 hel'l! i.lt·!lt,·d mcdi< of ill.\1/rouce hccunw uluJJJ'e-exisling condition:) lj'so. !hey muy he e!igihll' f(w the ik \1 f>rc- J : x i ~li llg ( 'onditinu ln\ur,m<Y Pion. Cull toll.fi't'e 1-Sf)() .. - !7-58~6 rTTY l- 8n6-5o!-J()(J-IJ (!,. ~ -;,;, Hll'li'.J'CiJI.g(J F onrl cih k 1!11 "1-'ind low· ,<;rote .. !nlr!ommorf:'.

42 CFR 435.308 State: Maryland Groups Covered A 1T ACHMENT 2.2-A Page 25 C. Optional Coverage of Medically Needy (continued) 4. Reserved for future use 5. X a. Financially eligible individuals who are not described in section C.3 above and who are under the age of- 2l_21 20 19 _ 18 or under age 19 who are full-time students in a secondary school or in the equivalent level of vocational or technical training Db. Reasonable classifications of financially eligible individuals under the ages of21 , 20, 19, or 18 as specified below: _ (I) Individuals for whom public agencies are assuming full or partial financial responsibility and who are: _(a) In foster homes (and who are under the age of__), _(b) In private institutions (and are under the age of__). TN # 11-20 Approval Date DEC 16 20'ft. Effective Date t:J m 6 0'2.. I, :kO ,, Supersedes TN # 92-11

1902(e)(4) of the Act A TI ACHMENT 2.2-A Page 6 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Maryland A. Mandatory Coverage -Categorically Needy and Other Required Special Groups (Continued) 12. Deemed Newborns: (42 CFR 435.117, 1902(e)(4) ofthe Act) A child born in the United States to a woman who was eligible for and receiving Medicaid (including coverage of an alien for labor and delivery as emergency medical services) for the date ofthe child's birth, including retroactively. The child is deemed eligible for one year from birth. 42 CFR 435.120 13. Aged, Blind, and Disabled Individuals Receiving Cash Assistance X a. Individuals receiving SSI: This includes beneficiaries' eligible spouses and persons receiving SSI benefits pending a final determination of blindness or disability or pending disposal of excess resources under an agreement with the Social Security Administration; and beginning January I, 1981 persons receiving SSI under section 1619(a) of the Act or considered to be receiving SSI under section 1619(b) of the Act. X Aged X Blind X Disabled TN# ll:2Q Approval DateBEC 1. 6 26f1 Effective Date () CT/)tje((_ · 11 ;;;._ tJ Jl Supersedes TN # 93-0 I

~ . DEP, RTME I' OF HEALTH A D HUMAN ERVICE CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL ANO NOTICE OF APPROVAL Of STATE PLAN MATERIAL I. TRANSMITTAL NUMBER: 11-2~ FORM APPROVED OMB NO. 0938~193 2. STATE Maryland FOR: CENTERS FOR MEDICARE & MEDICAID SERVICE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL ECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN 6. FEDERAL STATUT REGULATION CITATION: 1902 (e)(4) ofthe Social Securit Act I 903 (x) ofthe Social Security Act 8. PAGE UMBER OF THE PLAN ECTION OR ATIACHMENT: Page 6. Attachment 2.2-A Page 25, Attachment 2.2-A 4. PROPOSED EFFECTIVE DATE October 1. 20 I I a. FFY b. FFY 2013 9. PAGE NUMBER OF THE SUPER EDED PLAN SE TION OR ATIACHME T (lfApplicable: Page 6. Attachment 2.2-A (93-1) Page 25, At1achment 2.2-A (92-1 I I 0. BJECT OF AMENDMENT: To provide for a child who is born in the United tates to a woman who is eligible for and receiving Medicaid (including co erage of an alien for labor and delivery as emergenc medical services) to be automatically enrolled in Medicaid or CHIP for I year. This amendment eliminates the requirement that for a newborn to be deemed eligible. the mother must remain eligible and the child must remain in the same hou ehold as the mother. II. GOVERNOR'S REVI EW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMM NTS OF GOVERNOR'S OFFIC ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAY OF UBMITIAL - X OTHER. A SP Clf'l D: The ecretary of the Department of Health and Mental H giene 12. S IGNATU ~E 9lt~T7f-GENCY OFFICIAL: 16. RETURN TO: l :;ul f V / Susan Tucker -~3-. -T-Y-PE_D_N__,!A ... M~E-: ....!.C_h.:....a_r_le....:.s_J_. M-i-Ih-. g-ru-1.-J-r-. -------1 Executive Director ----------------------1 Office of Health Services 14. TITLE: Deputy Secretary, Office of Health Care Department of Health & Mental Hygiene _____ F:_l:..:.:.n:=an:.:.c::..:i.:..:n.-z.g' _ __,.. ___________ -1 201 W Preston t. I 1 floor 15. DATE SUBMITTED: Cf,/zq/zo J J Baltimore MD 21201 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: q ~ '1 I;< 0 II 1 8. DATE APPROVED: 23. REMARKS: FORM CMS-179 (07-92)

-~ DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS for MEDICARE & MEDICAID SE/MC£5 Region III/Division of Medicaid and Children's Health Operations SWIFT #012620124010 FFB 0 2 2012 Charles J. Milligan Jr., Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Room 525 Baltimore, MD 21201 Dear Mr. Milligan: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 11-21. This SPA adds language that was inadvertently dropped on Maryland SPA 11-04, which expanded coverage to otherwise pregnant women and children who are aliens, under the Children's Health Insurance Program Reauthorization Act (CHIPRA) Section 214 option. The added language is not directly related to SPA 11-04, but is standard language that addresses interstate residency agreements in determining eligibility for coverage. It is our understanding that this SPA is technical in nature and does not change any policy ofthe State. The effective date for this amendment is October I, 2011. The signed CMS-179 form and the approved State Plan pages are enclosed. If you have questions about this SPA, please contact Rosemary Feild at (215) 861-4278. Enclosure Do )lOU know someone who has hi!en denied medic·at insurance because of a pre-existing condition"! {fso. thev may be e!igiblefor the new Pre-Existing Condition Insurance Plan. Calltol!ji·ee 1-866-717-58]6 rTTY 1- 866-561-1 60-IJ or visit ww~-~.·. pcip. gov and click 0 11 "Find Your State·· to learn more.

Revision: CMS-PM- ATIACHMENT 2.6-A Page 3 (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa. _x_ Elected for pregnant women. _x_ Elected for children under age _x_. g. _x_ The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA section 214 option, it has verified, at the time ofthe individual's initial eligibility determination and at the time of the eligibility redetermination that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act. 4. Is a resident of the State, regardless of whether or not the individual maintains the residence permanently or maintains it at a fixed address. TN # 11-21 Supersedes TN # 11-04 [KJ State has interstate residency agreement with the following States: Texas, New Mexico, West Virginia, Louisiana, Iowa, New Jersey, Georgia, California, Florida, Tennessee, Pennsylvania 0 State has open agreement(s). 0 Not applicable; no residency requirement. Effective Date I 0 I cj' 0 I I

DEI'ARTME T Of J-IEALTH AND IIUMAo SERVICES HEAL Til CARE FINANCING ADMINISTRATIO, TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CE TERS FOR MEDICARE & MEDICAID ERVICES TO: REGIONAL ADMI ISTRATOR CENTER FOR MEDICARE & MEDICAID ERVICE DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): EW STATE PLAN 6. FEDERAL STATUT · REGULATION CITATION: 8. PAGE NUMBER OF THE PLAN ATTACHMENT: .PBf,C 66(c1) Attachment 2.6-A Page 3 OR MBER: F R 1 APPROVED OMB NO. 0938-0193 2. 'TATE Maryland . PROGRAM IDE TIFICATION: TITLE XIX OF THE SO 'IAL SECURITY ACT (MEDICAID) ED EFFECTIVE DATE October I, 20 I I [g) AME DMENT L B DGET IMPACT: 2011:$ 0 2012:$ 0 9. PAGE MBER OF THE PERSED D PLAN SECTION OR ATTACHMENT (((Applicoh/e): Page 66(a) (~ ~~~ • (I)- Attachment 2.6-A Page 3 ( 1-04) 10. SUBJECT OF AME orrect omissions. 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFfiCE REPORTED NO COM ME T 0 COMME TS Of GOVER OR' OFFICE E CLO ED 0 NO REPLY RECEIVED WITHIN 45 DAY OF SUBMITTAL 13. TYPED NAME: Charles J. Milligan, Jr. 14. TITLE: Deputy Secretary. Oftice of Health arc financing 15. DATES BMITTED: ll /J.t {UJ It 17. DATE RECEIVED: 23. REMARKS: FORM HCFA- l79 (07-92) [g) OTHER, AS PECIFIED: Susan J. Tucker, Executive Director Office of Health Services 16. RET R TO: Susan J. Tucker. Executive Director OilS - DHMH 20 1 W. Preston St.. 1 51 floor Baltimore, MD 21201 0 2 2012

QEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS for MEDICARE & MEDICAID SERVICES Region II@ivision of Medicaid and Children's Health Operations SWIFT #032920124016 MAY 3 0 2012 Charles J. Milligan Jr. Deputy Secretary Health Care Financing MD Department of Health and Mental Hygiene 201 West Preston Street, Room 525 Baltimore, MD 21201 Dear Mr. Milligan: Enclosed is a copy ofthe approved State Plan Amendment (SPA), Transmittal Number 12-03. This SPA provides assurance of compliance with the provider screening and enrollment provisions at 42 CFR 455, Subpart E. We appreciate the evaluation accompanying the SPA on the status in implementing the requirements and any barriers, as well as projected timeframes for completion of all actions. The effective date for this amendment is January 1, 2012. The signed CMS-179 form and the approved State Plan pages are enclosed. If you have questions about this SPA, please contact Andrea Cunningham of my staff at (215) 861-4325. Sincerely, Enclosure

79z-l STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Citation 1902( a )(77) 1902(a)(39) 1902(kk); P.L. 111-148 and P.L. 111-152 42 CFR455 Subpart E 42 CFR455.410 42 CFR455.412 42 CFR455.414 42 CFR 455.416 42 CFR 455.420 TN # 12-03 Supersedes TN # NEW State/Territory: ___:.M'-'=a"'-ry....,.l=an=d=----------- 4.46 Provider Screening and Enrollment The State Medicaid agency gives the following assurances: PROVIDER SCREENING X Assures that the State Medicaid agency complies with the process for screening providers under Section 1902(a)(39), 1902(a)(77) and 1902(kk) of the Act. ENROLLMENT AND SCREENING OF PROVIDERS X Assures enrolled providers will be screened in accordance with 42 CFR 455.400 et seq. X Assures that the State Medicaid agency requires all ordering or referring physicians or other professionals to be enrolled under the State plan or under a waiver of the Plan as a participating provider. VERIFICATION OF PROVIDER LICENSES X Assures that the State Medicaid agency has a method for verifying providers licensed by a State and that such providers licenses have not expired or have no current limitations. REVALIDATION OF ENROLLMENT X Assures that providers will be revalidated regardless of provider type at least every 5 years. TERMINATION OR DENIAL OF ENROLLMENT X Assures that the State Medicaid agency will comply with section 1902(a)(39) of the Act and with the requirements outlined in 42 CFR 455.416 for all terminations or denials of provider enrollment. REACTIVATION OF PROVIDER ENROLLMENT _x_ Assures that any reactivation of a provider will include re-screening and payment of application fees as required by 42 CFR 455.460. Approval Date MAY 3 0 2012 Effective Date ;;]/tAl U If-A. y f 1 d-lJ /.;J.._

. . 79z-2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT 42 CFR 455.422 42 CFR 455.432 42 CFR 455.434 42 CFR 455.436 42 CFR 455.440 42 CFR 455.450 42 CFR 455.460 42 CFR 455.470 TN# 12-03 Supersedes TN # NEW APPEAL RIGHTS _x_ Assures that all terminated providers and providers denied enrollment as a result of the requirements of 42 CFR 455.416 will have appeal rights available under procedures established by State law or regulation. SITE VISITS _x__ Assures that pre-enrollment and post-enrollment site visits of providers who are in "moderate" or "high" risk categories will occur. CRIMINAL BACKGROUND CHECKS _x_ Assures that providers, as a condition of enrollment, will be required to consent to criminal background checks including fingerprints, if required to do so under State law., or by the level of screening based on risk of fraud, waste or abuse for that category of provider. FEDERAL DATABASE CHECKS _X~_ Assures that the State Medicaid agency will perform Federal database checks on all providers or any person with an ownership or controlling interest or who is an agent or managing employee of the provider. NA TlONAL PROVIDER IDENTIFIER _x__ Assures that the State Medicaid agency requires the National Provider Identifier of any ordering or referring physician or other professional to be specified on any claim for payment that is based on an order or referral of the physician or other professional. SCREENING LEVELS FOR MEDICAID PROVIDERS _X~_ Assures that the State Medicaid agency complies with 1902(a)(77) and 1902(kk) of the Act and with the requirements outlined in 42 CFR 455.450 for screening levels based upon the categorical risk level determined for a provider. APPLICATION FEE _x__ Assures that the State Medicaid agency complies with the requirements for collection of the application fee set forth in section 1866G)(2)(C) of the Act and 42 CFR 455.460. TEMPORARY MORATORIUM ON ENROLLMENT OF NEW PROVIDERS OR SUPPLIERS ___x_ Assures that the State Medicaid agency complies with any temporary moratorium on the enrollment of new providers or provider types imposed by the Secretary under section 1866(j)(7) and 1902(kk)(4) of the Act, subject to any determination by the State and written notice to the Secretary that such a temporary moratorium would not adversely impact beneficiaries' access to medical assistance. Approval Date MAY 3 0 2(Jf2 Effective Date 7/tlf/U M<f I 1 .:1 0 /,;1..._

1\LOF I. TRA fOR: E TER f'OR MEDI ARE c· MEDI AID ECTION Page !)z 1-2 1 EW) 10. OTH ·R. PE IFI -D: The do.: ignee of the Secretary of the DCJ)artment of lieahh and Mental Hygiene crvicc - Mental llygi ne !7. DATE RECEIVED: MAY 3 .0 -2012 :r R 1 C o1 -1 9(07-92)

Table of Contents State/Territory N arne: Maryland State Plan Amendment (SPA) #: 13-16 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS FOR MEDICARE & MEDICAID SERVICES Region III/Division of Medicaid and Children's Health Operations SWIFT #090920134026 OCT 2 5 2013 Charles 1. Milligan Jr. Deputy Secretary Health Care Financing Maryland Department of Health and Mental Hygiene 201 West Preston Street, Room 525 Baltimore, MD 21201 Dear Mr. Milligan: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 13-16. This SPA is to clean-up Maryland's State Plan in order to bring Maryland's State Plan into technical conformity with Maryland's income disregard practice for eligible children age one to eighteen. The effective date for this amendment is July 1, 2013. The signed CMS-179 form and the approved State Plan pages are enclosed. If you have questions about this SPA, please contact Lieutenant Commander Andrea Cunningham of my staff at (215) 861-4325. Sincerely, Enclosure (b) (1) (A), (b) (1) (A) (b(b) (1) (A), (b) (b) (1) (A), (b) (b) (b) (1) (A), (b) /S/

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND I-lUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): I. TRANSMITfAL NUMBER: 13-16 FORM AI'J'R() VUJ OMB NO 093 ~- 0 1 93 2. STATE Maryland 3. PROGRAM IDENTIFICATION: TiTLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE July L 2013 NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN ---::-~; X AM ENDMENT COMPLETE BLOCKS 6 '_!'HRU I 0 IF THIS IS AN AMENDMENT (Se arute Transmittal (or each amenJmellf) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Section 1902(a)(l O)(A)(ii)(XJV) of the Social Security Act a. FFY 2013 $ 0.00 Section 1902 (r)(2) of the Social Security Act b. FFY 2014 .$_ 0.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Page ! , ,6.ttsehrnet,t2.~~/\.ll __ .._ \ ..., 1 ·A S~\e.'CY'\e" -u r-n~o .. c..n~enT ..t.. •LD 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (lj'Applicab/e): Page I. Attttehlllent 2.6•A ~ ~ \ 'A 'Su..~~\e...~e...f"'\"'"" ~0... "'1:) f\~o.ch<n~C'I\2.l9 10. SUBJECT OF AMENDMENT: Submitting clean-up SPA.. in order to bring Maryland's plan into technical confom1ity with Maryland's income disregard practice and intentions prior to January 1, 2014. I .1. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITI'AL X OTHER, AS SPECIFIED: Susan J. Tucker Executive Director, Office of Health Services Y OFFICIAL: 16. RETURN TO: Susan Tucker - 13-. T_Y_P_E_· D- N-A-tv-=1=-E-: _,C_h...La-rl.._es__,_J._,M'---i 1-1 i-ga-t-1,-J-r.-- --- - - l Executive Director ---------------- - --- -1 Office of Health Services 14. TITLE: Deputy Secretary Department of Health & Mental Hygiene -o-:---=-~c:-:-:0-=-=ffi ...,.tc ,..,:e"""o:-=f-::::-l_ -le-'- ·a-'-lt-'- · b_C-'-a-'-r-'-e-:>F,in-:-a_n_c.,.- in_,_)'--....,..-:o--,--,,_...---j 20 I W Preston St, I 51 tloor 15. DATE SUBMITI'ED: Baltimore MD 21201 17. DATE RECEIVED: FORM CMS-179 (07-92) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A) (b) (b) (1) (A), (b) /S/ /S/

SUPPLEMENT Sa to ATTACHMENT 2.6-A Page 1 OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Maryland MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902(r)(2) OF THE ACT __ Section 1902(f) State X Non-Section 1902(f) State The more liberal income methodology is as follows: Countable net income which exceeds 200% ofthe FPL but is less than 300% of the FPL will be disregarded for children eligible under Section 1902(a)(l O)(A)(ii)(XIV). *More liberal methods may not result in exceeding gross income limitations under section 1903(f). TNNo. 13-16 Supersedes Approval Date ------"Q'----=C'----'-T---2_,5~2 0~1...,..3 _ Effective Date J U L 0 1 2 0 13 TNNo. 93-1

Table of Contents State/Territory Name: MARYLAND State Plan Amendment (SPA)#: MD-13-0020-MMl This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan- Supporting Documents

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS FOR MEDICARE & MEDICAID SERVICES Region Ill/Division of Medicaid and Children's Health Operations SWIFT #:121220134020 DEC 13 2013 Charles 1. Milligan Jr. Deputy Secretary Health Care Financing Maryland Department of Health and Mental Hygiene 201 West Preston Street, Room 525 Baltimore, MD 21201 Dear Mr. Milligan: Enclosed is a copy ofthe approved State Plan Amendment (SPA), Transmittal Number 13-0020- MM1 . This SPA identifies MAGI-based eligibility groups and incorporates general eligibility requirements into the State ofMaryland's State Plan in accordance with the Affordable Care Act. The effective date for this SPA is January 1, 2014. Enclosed is a copy of the new State Plan pages: • S14, pages 1 through 6 • S25, pages 1 through 3 • S28, pages 1 through 2 • S30, pages 1 through 5 • S32, pages 1 through 2 • S33, page 1 • S50, page 1 • S51, page 1 • S52, pages 1 through 3 • S53, pages 1 through 2 • S54, pages 1 through 3 • S55, page 1 • S57, pages 1 through 2 • S59, page 1

Page 2 - Charles J. Milligan, Jr. If you have questions about this SPA, please contact Lieutenant Commander Andrea Cunningham of my staff at (215) 861-4325. Sincerely, Enclosure (b) (1) (A), (b) (b) (b) (1) (A), (b (b) (1) (A), (b) (b) (1) (A), (b) /S/

MD.0575.ROO.OO -Jan 01, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) State(ferritory name: Maryland Transmittal Number: Page 1 of 1 Please enter the Transmittal Number (fN) 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. MD 13-0020 Prop~S.~~-_!!:!!t_!~~~ve ~ate 01/01/2014 . (mm / ddl yyyy) Federal Statute/Regulation Citation _______ _ 42 CFR 435.110 1902(a)(10)(A)(i)(I), 1931(b) and (d); 42 CFR 435.1161902(a)(10)(A)(i)(III) and (IV), 1902(a. Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $473933493.00 Second Year 2015 $851265787.00 Subject of Amendment Maryland's updated MAGI Eligibility requirements for Maryland Medicaid Population. Governor's Office Review D Governor's office reported no comment D Comments of Governor's office received Describe: .. --························--······ D No reply received within 45 days of submittal ~ Other, as specified Describe: Authority delegated to Deputy Secretary for Health Care Financing, Charles Milligan. Signature of State Agency Official Submitted By: Molly Marra Last Revision Date: Dec 11,2013 Submit Date: Dec 11,2013 .C:l - .111.\_ .... - 1- : _ ..J ~ L - .. - \ 0TT4'ni'\ ("'1 ... ~-~ ' T""\~~r-'ITT\'K --1· - "1\"'A"T""\\ C'T'\A _ \ -,.KA.r'IT _ 1,.-,TTTT'\T"'l ~ - : 1 ,., / 1 ,..., ,,....." 1 ....,

TRANSMITTAL NUMBER: 13- 0020 SUPERSEDING PAGES OF STATE PLAN MATERIAL STATE: Maryland Pages or sections of pages being superseded by S25 , S2 8 , S30, S51, S52, S53 , S54 , S57 , and S14 and related pages or sections of pages being deleted as obsolete State Plan Section Complete Pages Removed Partial Pages Removed Page 1 Page 2 , A. 2 . b Page 3 Page 2 , A. 2 . c Page 3a Page 2a , A. 3 Page 4 Page 5 , A. 10 Page 4a Page 9c . 8 . 1. remove Attachment 2.2-A Supplement 1 to Attachment 2.2-A Attachment 2.6-A Page Page Page Page Page Page Page Page Page Page Page Page Page Page Page Page 12 13 13a 14 14a 21 23 23b 23f 1 3b lla 19 19a 19b 21 1 " Caretaker Relatives " and " Pregnant Women" Page 20 8 . 14 Page 23c , 8.20 Page 23c , 8 . 22 Page 25 , c. 4 Page 1 , A. 2 . a . (i} & (iii} Page 6 related to AFDC recipients , pregnant women , infants , and children Page 7 , 1. a (1} and (2} Page 12 , C . l.e(2} related to income of

... parents and pregnant women Page 18.C.5.e Page 25, ll.a.(3) Supplement 1 to Attachment Pages 1 - 3 2.6-A Supplement 2 to Attachment Pages 1 5 - 2.6-A Pages 2 & 6, groups Supplement Ba to Attachment Pages 1, 3, 5, and 7 related to 2.6-A categorically needy groups and family and children Pages 2, 3, & 5, Supplement 8b to Attachment Page 4 related to 2.6-A categorically needy groups for families and children Supplement 13 to Attachment Page 1 - 4 2.6-A 2

Medicaid Eligibility Additional incremental amount Household size Standard ($) r. Yes (' No ~+ 1 187 X Increment amou nt $ 168.7 + 2 322 X + 3 410 X + 4 495 I~ X + 5 574 X + 6 633 X + 7 713 X + 8 785 X + 9 849 X + 10 917 X + 11 984 X + 12 1,052 X + 13 1,118 X + 14 1.184 X + 15 1,253 X + 16 1,321 .X The dollar amounts increase automatically each year (' Yes r. No AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amoupt - Automati~ Increase Option The standard is as follows: (e' Statewide standard (' Standard varies by region TN# MD-13-0020-MM1 APPROVED: 12/13/2013 I EFFECTIVE: 01/01/2014 Page 2 of (j

Medicaid Eligibility (' Standard varies by living arrangement (' Standard varies in some other way Enter the statewide standa1d ,11. -,,_ .e· :: ;,;,-" Additional incremental amount Household size Standard ($) le' Yes (' No + 1 165 X Increment amount $ 161 I + 2 292 X ' + 3 373 X ,+ 4 450 X + 5 521 X i'+ 6 573 X + 7 645 .X + R 709 X + 9 766 X + 10 826 X + 11 886 X + 12 946 X + 13 1,004 X ' + 14 1,063 X I + 15 1,124 X + 16 1,184 X The dollar amounts increase automatically each year ('Yes le' No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount -Automatic Increase· Option TN# MD-1 3-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01 /2014 Page 3 of 6

Medicaid Eligibility The standard is as follows: (' Statewide standard (' Standard varies by region (' Standard varies by livi ng arrangement (' Standard varies in some other way The dollar amounts increase automatically each year (' Yes (' No AFDC Need Standard in Effect As of July 16, 1996 ,, Income Standard Entry - Dollar Amount - Automatic Increase Option *li Sl3a "" The standard is as follows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year (' Yes (' No AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI·U) since such.date; , co Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year (' Yes (' No TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 4 of fi

Medicaid Eligibility MAGI-equivalent AFDC Payment Standard in Effect As of July16, 1996, increased by no more than .the percentage increase in the Consumer Price llid~l fc;r uJti'Jin oonsumers (CPI-U) since such date Income Standard Entry ~ Dollar Amount - Automati¢ In~rease Option . ,,,;. ,, ; .. S13a, The standard is as follows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year (' Yes (' No TANF payment standard :-:;:; l • . , ' ' ~ l ". Income Standard Entry - Dollar Amount - Automatic Increase Option .~ S13a The standard is as follows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year (' Yes ('No MAGI-equivalent TANF payment standard y ·''·~.~ ''·:•/;1 Jii' ' "''•• Income .Standard Entry - Dollar Amount - Automatic Increase Option l··,t, . I · "sHa The standard is as follows: (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 5 of o

Medicaid Eligibility The dollar amounts increase automatically each year ("Yes ("No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Ofticer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 6 of 6

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups ~ Mandatory Coverage Parents and Other Caretaker Relatives 42 CFR 435.110 1902(a)(10)(A)(i)(I) 1931(b) and (d) 825 ~ Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. 0 The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, ~ provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. D Options relating to the definition of caretaker relative (select any that apply): lXI Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or l- care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. (' The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): ~ Have household income at or below the standard established by the state. ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SlO MAGI- Based Income Methodologies, completed by the state. ~ Income standard used for this group ~ Minimum income standard The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1. 1988. converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards. 0 The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. ~ Maximum income standard TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 1 of 3

Medicaid Eligibility The state certifies that it has submitted and received approval for its converted income standard(s) for parents and [Z] other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. '""' -,;;- ' .. An attachment is submitted. y The state's maximum income standard for this eligibility group is: (' The state's effective income level for section 1931 families under the Medicaid state plan as of March 23. 2010. converted to a MAGI-equivalent percent of FPL or amounts by household size. (e' The state's effective income level for section 1931 families under the Medicaid state plan as of December 31. 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaidl115 (' demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid J 115 (' demonstration as of December 31 , 2013. converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: (e' A percentage of the federal poverty level: ~ % (' The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in Sl4 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage (' increase in the Consumer Price Index for urban consumers (CPI-U) since such date. converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards. (' The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. (' Other dollar amount ~ Income standard chosen: Indicate the state's income standard used for this eligibility group: (' The minimum income standard (e' The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage (' increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards. (' Another income standard in-between the minimum and maximum standards allowed ~ There is no resource test for this eligibility group. ~ Presumptive Eligibility TN# M D-13-0020-M M 1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 2 of 3

Medicaid Eligibility The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 ( 42 CFR 435.11 8) eligibility groups when determined presumptively eligible. (' Yes (e' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form , please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 3 of 3

Medicaid Eligibility Eligibility Groups· Maiulatory Coverage Pregnant Women. OMB Control Number 0938-1148 OMB Expiration date· 10/31!2014 S28 42 CFR 435.116 1902(a)(10)(A)(i)(III) and (IV) 1902(a)(10)(A)(ii)(I). (IV) and (IX) 1931(b) and (d) 1920 ~ Pregnant Women- Women who are pregnant or post-partum, with household income at or below a standard established by the state. 0 The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110. (e Yes (' No ~MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SlO MAGI-Based Income Methodologies, completed by the state. ~ Income standard used for this group ~ Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.) The state had an income standard higher than 133% rl>L established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so. (e Yes (' No Enter the amount of the minimum income standard (no higher than 185% FPL):~ % FPL ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant 0 women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. An attachment is submitted. ·'.i> . "',~ ,.. I ':~' .<· '' The state's maximum income standard for this eligibility group is: r. The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(Ill) (qualified pregnant women), 1902(a)(lO)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women). 1902(a)(10) (A)(ii)(l) (pregnant women who meet AFDC financial eligibility criteria) and l902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01101/2014 Page 1 of 2

' Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income famiLies), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- (' related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(l0) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' 185% FPL The amount of the maximum income standard is:EJ % FPL ~ Income standard chosen Indicate the state's income standard used for this eligibility group: (' The minimum income standard (e' The maximum income standard (' Another income standard in-between the minimum and maximum standards allowed. ~ There is no resource test for this eligibility group. ~ Benefits for individuals in this eligibility group consist of the following: (e' All pregnant women eligible under this group receive full Medicaid coverage under this state plan. (' Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. ~ Presumptive Eligibility The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. (' Yes (e' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed. and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 2 of 2

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expi ration date: 10/31/2014 Eligibility Groups · Mandatory CQverage Infants and Children under Age 19 42 CFR 435.118 1902(a)(10)(A)(i)(lll), (IV), (VI) and (VII) 1902(a)(lO)(A)(ii)(IV) and (IX) 1931(b) and (d) ~ Infants and Children under Age 19- Infants and children under age 19 with household income at or below standards established by the state based on age group. [Z] The state attests that it operates this eligibility group in accordance with the following provisions: ~ Children qualifying under this eligibility group must meet the following criteria: ~ Are under age 19 ~ Have household income at or below the standard established by the state. ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SlO MAGI- Based Income Methodologies, completed by the state. · ~ Income standard used for infants under age one ~ Minimum income standard The state had an income standard higher than 133% FPL established as of December 19. 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. (e' Yes (' No Enter the amount of the minimum income standard (no higher than 185% FPL):~ % FPL ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for infants [Z] under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. ~--~~~==~~~--~~~~~~====~==~-----. An attachment is ~ubrnittea : The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related (e' infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid stale plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN# MD-13-0020-MM1 APPPROVED 12/13/2013 EFFECTIVE: 01101/2014 Page 1 of 5

Medicaid Eligibility The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related (' infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(lV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' 185% FPL Enter the amount of the maximum income standard: ~ % FPL ~ Income standard chosen The state's income standard used for infants under age one is: (e' The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(lll) (qualified children), 1902(a)(10) C (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(lX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010. converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants (' under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(lX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(lV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and C if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and C if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. ~ Income standard for children age one through age five, inclusive ~ Minimum income standard TN# MD-13-0020-MM1 APPPROVED 12/13/2013 EFFECTIVE: 01/01/201 4 Page 2 of 5

Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for children 0 age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. An attachment is submitted. The state's maximum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 1931 (low- le' income families), 1902(a)(lO)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- (' income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 3L 2013, converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: ~ % FPL ~ Income standard chosen The state's income standard used for children age one through five is: le' The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(lll) (qualified children), (' 1902(a)(10)(A)(i)(Vl) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children); in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children (' age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children). 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. TN# MD-13-0020-MM1 APPPROVED 12/13/2013 EFFECTIVE: 01/01/2014 Page 3 of 5

Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and (' if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and r if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted loa MAGI- equivalent percent of FPL. (") Another income standard in-between the minimum and maximum standards allowed, provided it is higher than j the effective income standard for this age group in the state plan as of March 23, 2010. ~ Income standard for children age six through age eighteen, inclusive ~ Minimum income standard The minimum income standard used for this age group is 133% FPL. ~ Maximum income standard The state certifies that it has submitted and received approval for its converted income standard(s) for children age [{] six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. An attachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (' (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(Vll) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty (' level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 3 I, 2013, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. (' The stale's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Ce' 133% FPL ~ Income standard chosen The state's income standard used for children age six through eighteen is: TN# MD-13-0020-MM1 APPPROVED 12/13/2013 EFFECTIVE: 01/01/2014 Page 4 of 5

Medicaid Eligibility le' The maximum income standard lf not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(lll) (qualified children), (' 1902(a)(10)(A)(i)(VI1) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children (' age six through eighteen under sections 1931 (low-income families), 1902(a)(10){A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children C age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and (' if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. (' Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. ~ There is no resource test for this eligibility group. ~ Presumptive Eligibility The state covers children when determined presumptively eligible by a qualified entity. (' Yes le' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn : PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN# MD-13-0020-MM1 APPPROVED 12/13/2013 EFFECTIVE: 01101/2014 Page 5 of 5

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 Eligibility Groups - Mandatory Coverage Adult Group 1902( a )(lO)(A)(i)(Vlli) 42 CFR 435.119 The state covers the Adult Group as described at 42 CFR 435.119. ' <! Yes (' No 832 ~ Adult Group -Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. [Z] The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Have attained age 19 but not age 65. ~ Are not pregnant. ~ Are not entitled to or enrolled for Part A or B Medicare benefits. ~ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B. Note: In 209(b) slates, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible. ~ Have household income at or below 133% FPL. ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based • Income Methodologies, completed by the state. ~ There is no resource test for this eligibility group. Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is ~ receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4. ('-Under age 19, or C. A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010: C Under age 20 (e Under age 21 ~ Presumptive Eligibility The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. (' Yes te No TN# MD-13-0020-MM1 APPROVED 12/13/2013 EFFECTIVE: 01/01/201 4 Page 1 of2

Medicaid Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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. TN# MD-13-0020-MM1 APPROVED 12/13/2013 EFFECTIVE: 01/01/2014 Page 2 of2

Medicaid Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children 42 CFR 435.150 1902(a)(10)(A)(i)(IX) OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 .833 ~ Fonner Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. [{] The state attests that it operates this eligibility group under the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Are under age 26. ~ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under • this group takes precedence over eligibility under the Adult Group. Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state ~plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. The state elects to cover children who were in foster care and on Medicaid in~ state at the time they turned 18 or aged out of the foster care system. ("Yes (i' No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 ( 42 CFR 435.118) eligibility groups when determined presumptively eligible. ("Yes (e' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN# MD-13-0020-MM1 APPROVED 12/13/2013 EFFECTIVE: 01/01/2014 Page 1 of J

~s ---- Medicaid Eligibility Eligibility Groups - Options for Coverage Individuals above 133% FPL 1902(a)(10)(A)(ii)(XX) 1902(hh) 42 CFR 435.218 OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 850 Individuals above 133% FPL- The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218. rYes (e' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this fom1, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01 /201 4 Page 1 of 1

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 - Eligibility Groups - Options for Coverage 851 Optional Coverage of Parents and Other Caretaker Relatives 42 CFR 435.220 1902(a)(lO)(A)(ii)(I) Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. ('Yes r. No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 1 of 1

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 Eligibility Groups - Options for Coverage Reasonable Classification of Individuals under Age 21 42 CFR 435.222 1902(a )(10)(A )(ii)(I) 1902(a)(l O)(A)(ii)(IV) S52 Reasonable Classification of Individuals under Age 21 -The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222. (i' Yes (' No [2] The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria: ~ Be under age 21, or a lower age, as defined within the reasonable classification. ~ Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification. ~ Not be eligible and enrolled for mandatory coverage under the state plan. ~ MAGI-based income methodologies arc used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. r. Yes (' No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. (' Yes (i' No Reasonable Classifications Previously Covered The state elects the option to include in this eligibility group reasonable classifications that were covered under the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. (i' Yes (' No The state covers all children under a specified age limit, no higher than any age limit and/or income standard covered in the state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, provided the income standard is higher than the current mandatory income standard for the individual's age. Higher income standards may include the disregard of all income. (' Yes <i'' No TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 1 of 3

Medicaid Eligibility The state covers reasonable classifications of children that were covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the curre nt mandatory income standard for the age group. r. Yes (' No The previously covered reasonable classifications to be included are: PreyiQusl}' Covered ReasQnable Classifi~atiQns Indyded Reasonable Classifications of Children Sll D Individuals for whom public agencies are assuming full or partial financial responsibility. D Individuals in adoptions subsidized in full or part by a public agency D Individuals in nursing facilities, if nursing facility services are provided under this plan D Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan . !ZI Other reasonable classifications Name of classification Description Age Limit + Pregnant teens Pregnant teens Iunder age 18 I X Enter the income standard used for these classifications (which may be no higher than the highest standard used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013). Click here once 511 form above is complete to view the income standards form. = I Pregnant teens [!] Income standard used [!] Minimum income standard The minimum income standard for this classification of children must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group. [!) Maximum income standard No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. r. Yes (' No The state's maximum standard for this classification of children is no income test (all income is disregarded). TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/0112014 Page 2 of 3

Medicaid Eligibility ~ Income standard chosen Individuals qualify under this classification under the following income standard: c;: This classification does not use an income test (all income is disregarded). (' Another income standard higher than the minimum income standard. New reasonable classifications covered If the state has not elected to cover the Adult Group (42 CFR 435.119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage. The state does .!1Qi cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted to a MAGI-equivalent standard. (' Yes (e No ~ There is no resource test for this eligibility group. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05. Baltimore, Maryland 21244-1850. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/201 4 Page3 of3

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 Eligibility Groups- Options for Coverage Children with Non IV-E Adoption Assistance 42 CFR 435.227 1902( a )(lO)(A)(ii)(VIII) Children with Non IV -E Adoption Assistance- The state elects to cover children with special needs for whom there is a non lV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227. {e Yes (' No [Z] The state attests that it operates this eligibility group in accordance with the following provisions: [!] Individuals qualifying under this eligibility group must meet the following criteria: [!] The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special • needs for medical or rehabilitative care; [!] Are under the following age (see the Guidance for restrictions on the selection of an age): ~ Under age 21 (' Under age 20 (' Under age 19 (' Under age 18 [!] MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SlO MAGI- Based Income Methodologies, completed by the state. The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23. 20 lO or December 31. 2013. {e Yes (' No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. {e Yes (' No 853 [!] Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to • the execution of the adoption agreement. The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. {e Yes (' No [!] Income standard used for this eligibility group [!] Minimum income standard The minimum income standard for this eligibility group is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. [!] Maximum income standard TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 1 of 2

Medicaid Eligibility No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. le' Yes (' No ~ No income test was used {all income was disregarded) for this eligibility group under (check all that apply): [g) The Medicaid state plan as of March 23, 2010. [g) The Medicaid state plan as of December 31, 2013. 0 A Medicaid 1115 Demonstration as of March 23, 2010. 0 A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). ~ Income standard chosen Individuals qualify under this eligibility group under the following income standard, which must be higher than the minimum for this child's age: This eligibility group does not use an income test (all income is disregarded). ~ There is no resource test for this eligibility group. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this infom1ation 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. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 2 of2

Medicaid Eligibility Eligibility Groups - Options for Coverage Optional Targeted Low Income Children 1902( a )(10)(A )(ii)(XIV) 42 CFR 435.229 and 435.4 1905( u )(2)(B) OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 S54 Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. (e' Yes (' No [Z] The state attests that it operates this eligibility group in accordance with the following provisions: 00 Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group. OO MAGI-based income methodologies arc used in calculating household income. Please refer as necessary to SlO MAGI- • Based Income Methodologies, completed by the state. The state covered this eligibility group in the state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. (e' Yes (' No The state also covered this eligibility group in the state plan as of March 23, 2010. (e' Yes (' No OO Until October 1, 2019, states must include at least those individuals covered as of March 23, 2010, but may cover • additional individuals. Effective October 1, 2019, states may reduce or eliminate coverage for this group. 00 Individuals are covered under this eligibility group, as follows: (e' All children under age 18 or 19 are covered: (e' Under age 19 (' Under age 18 (' The reasonable classification of children covered is: 00 Income standard used for this classification 00 Minimum income standard The income standard for this classification of children must exceed the lowest income standard chosen for children in the age group selected above, under the mandatory Infants and Children under Age 19 eligibility group. 00 Maximum income standard TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01 /2014 Page 1 of 3

\ Medicaid Eligibility The state certifies that it has submitted and received approval for its converted income standard(s) for this [ZJ classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: (i' The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for this classification of children under the Medicaid State Plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for this classification of children under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for this classification of children under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' 200% FPL. (' A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points. ~ The state's maximum income standard for this classification of children (which must exceed the • minimum for the classification) is: ~ % FPL ~ Income standard chosen, which must exceed the minimum income standard Individuals qualify under the following income standard: (i' The maximum income standard. (' The state's effective income level for this eligibility group under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective (' income level for this eligibility group under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective (' income level for this eligibility group under a Medicaid1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective (' income level for this eligibility group under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' If higher than the effective income level used under the state plan as of March 23, 2010, 200% FPL. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 2 of 3

' Medicaid Eligibility If higher than the effective income level used under the state plan as of March 23, 2010, a percentage of the (' FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points. (' Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this eligibility group in the state plan as of March 23, 2010. The income standard for this eligibility group is: ~ % FPL ~ There is no resource test for this eligibility group. ~ Presumptive Eligibility Presumptive eligibility for this group depends upon the selection of presumptive eligibility for the Infants and Children ~ under Age 19 eligibility group. If presumptive eligibility is done for that group, it is done for this group under the same provisions. 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. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 3 of 3

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 Eligibility Groups - Options for Coverage sss Individuals with Tuberculosis 1902(a)( JO)(A)(ii)(Xll) 1902(z) Individuals with Tuberculosis- The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services. (' Yes (; No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy or 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. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 1 of I

..... Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 Eligibility Groups - Options for Coverage Independent Foster Care Adolescents 42 CFR 435.226 1902(a)(10)(A)(ii)(XVII) Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21 , who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226. le' Yes (' No 0 The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Are under the following age (8 Under age 21 (' Under age 20 (' Under age 19 ~ Were in foster care under the responsibility of a state on thei r 18th birthday. ~ Are not eligible and enrolled for mandatory coverage under the Medicaid state plan. ~ Have household income at or below a standard established by the state. S57 ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SlO MAGI- Based Income Methodologies, completed by the state. The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013. le' Yes (' No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. le' Yes (' No ~ The state covers children under this eligibility group, as follows (selection may not be more restrictive than the coverage in the Medicaid state plan as of March 23, 2010 until October 1, 2019, nor more liberal than the most liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013): ce All children under the age selected (' A reasonable classification of children under the age selected: ~ Income standard used for this eligibility group ~ Minimum income standard The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 1 of 2

Medicaid Eligibility ~ Maximum income standard No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. {e Yes (' No ~ No income test was used (all income was disregarded) for this eligibility group under (check all that apply): 0 The Medicaid state plan as of March 23, 2010. [8J The Medicaid state plan as of December 31, 2013. 0 A Medicaid 1115 demonstration as of March 23, 2010. 0 A Medicaid 1115 demonstration as of December 31,2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). ~ Income standard chosen Individuals qualify under this eligibility group under the following income standard: (' The minimum standard. {e This eligibility group does not use an income test (all income is disregarded). Another income standard higher than both the minimum income standard and the effective income level C for independent foster care adolescents in the Medicaid state plan as of March 23. 2010. converted to a MAGI equivalent. ~ There is no resource test for this eligibility group. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this infom1ation 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 Ofticer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN# MD-13-0020-MM 1 APPROVED: 12/1 3/201 3 EFFECTIVE: 01/01/2014 Page2 of 2

Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date· 10/31/2014 Eligibility Groups - Options for Coverage 859 Individuals Eligible for Family Planning Services 1902(a)(lO)(A)(ii)(XXI) 42 CFR 435.214 Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. (' Yes r. No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014 Page 1 of 1

Modified Adjusted Gross Income (MAGI) Conversion Plan This MAGI Conversion Plan is being submitted to CMS by Maryland as required by Section 1902(e)(14)(E) of the Social Security Act, which requires each state to submit for approval the income eligibility thresholds for Medicaid and the Children's Health Insurance Program (CHIP) proposed to be established using modified adjusted gross income (MAGI). As described in the December 28, 2012 State Health Officials' Letter on Modified Adjusted Gross Income (MAGI) income conversion, states can choose among three options to convert net standards for Medicaid and CHIP to MAGI equivalent standards. 1 The purpose of the MAGI Conversion Plan is to provide CMS with information about each state's MAGI conversion methodology, as well as the data used and results of conversion. CMS will be reviewing the submitted materials and notifying the State with their approval or disapproval by June 15,2013. Eligibility and FMAP claiming conversions. States are required to submit information about their conversion methodology, data and results for income conversions related to eligibility and those required for FMAP claiming in accordance with CMS' FMAP rule. For additional information about the FMAP rule, please see: https://s3.amazonaws.com/public-inspection.federalregister.gov/2013- 07599.pdf. Note about Income Eligibility Conversions and State Plan Amendments: Converted income standards will be used to set maximum MAGI-equivalent standards for adults in 2014 and will be used as the actual income standard in effect for children through October 2019. States will use the state plan amendment (SPA) process to identify the minimum and maximum MAGI-equivalent standards and to select the state's MAGI-based income standard for each eligibility group to which MAGI will apply in 2014. For adults for whom the Maintenance of Effort requirement expires in 2014, the selected income standard in the SPA will be anywhere between the minimum allowed and the maximum derived through the income conversion process. Please indicate the MAGI conversion method chosen by your state and follow the appropriate directions: 0 .option 1- Standardized Methodology with SIPP data Attach Excel spreadsheet with finalized SIPP results of eligibility and FMAP conversions to this cover page and submit to incomeconversion@cms.hhs.gov . ../ Option 2 - Standardized Methodology with State data Please follow the instructions below and submit this plan to incomeconversion@cms.hhs.gov. 0 Option 3- State proposed Alternative Method Please follow the instructions below and submit this plan to incomeconversion@cms.hhs.gov. 1 SHO letter available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SH012003.pdf Page 1 TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01/2014

Part 1 -Conversions for Eligibility Part 2 - Conversions for FMAP Claiming Pages to Due Date Pages to Due Date Complete Complete Standardized Page 1 May 31,2013 Page 1 August 1, 2013 Methodology Standardized Page 3-10 April 30, 2013 Pages 13-18 August 1, 2013 Methodology with State Data Alternative Page 3-12 April 30, 2013 Pages 13-18 August 1, 2013 Methodology Page 2 TN# MD-13-0020-MM1 APPROVED: 12/13/2013 EFFECTIVE: 01/01 /2014

-; z 'It s:: ~ c..> 6 0 I'J 0 ~ s:: ~ }> lJ lJ ::0 0 < m 0 ~ ~ c..> i\3 0 ~ c..> m -n -n m () -; < rn 0 ~ 0 ~ i\3 ~ ~ Standardized Methodology with State Data Method and Alternative Method: Please provide a state contact who can answer questions about the conversion plan, data, and methods: Name: Alice Middleton Title: Deputy Director, Planning Administration, Health Care Financing, DHMH E-mail: alice.middleton@maryland.gov Phone: 410-767-3419 Supplemental Information: In addition to the information provided in the attached MAGI Conversion Plan, during the review and approval process, CMS may determine that supplemental information regarding the income conversion results is necessary. If CMS determines that a supplemental review of these results is necessary, your state may be required to submit: • Descriptive statistics of the data used. Such descriptive statistics could include for each eligibility group converted with state data: o Net income statistics and disregard statistics for the full population or sample and for the population used in conversion (e.g., the 25% band) including: Total N, Mean Net Income, Standard Deviation of Mean Net Income, Median Net Income, and Number of individuals with Positive Net Income • Data files used for conversion • Annotated programming code used in the analysis Page 3

--1 z "" s:: t? w b 0 ""' 0 ~ s:: )> -o -o ::0 0 < m q ~ ~ w ;;::; 0 ~ w m , , m 0 --1 < f1:1 ~ 0 ~ ;;::; ~ .j>. PART 1: ELIGIBILITY CONVERSIONS- TABLE 1- DUE APRIL 30, 2013 For States Using Standardized Methodology with State Data Or Alternative Method Please fill out Table 1 below to provide CMS with information about how state data were used for MAGI income conversion. All cells in rows for eligibility groups that do not have a converted income standard in your state (for example, if your state does not cover independent foster care adolescents or does not apply an income standard to this group) should be marked "N/A." Instructions for Table 1: SIPP results used: Your state may have used SIPP results for converting some groups. For conversions based on SIPP, please mark yes in the first column of Table 1 and provide the converted standard from those results. 2 Please list the group below (e.g., pregnant women) and an explanation of why the SIPP results are being used for this eligibility group (e.g., data unavailable). Attach additional pages if necessary. Note that for groups that need to be converted both for eligibility and FMAP purposes (e.g,. childless adults) the same income conversion method/data source (i.e., SIPP or state data) must be used. Maryland is using state data for coverage groups where data is reliable, available, and where it will have an impact on our Medicaid program after January 1, 2014. These groups are children ages 1 to 5, optional reasonable classifications of individuals under age 21, and parents under section 1931. For all other groups, Maryland is using SIPP results. The following groups will be converted using SIPP data: • Pregnant women, full benefits- The sample size in our Pll coverage group (pregnant women 200% FPL- 250% FPL) only contains approximately 500 enrollees in any given month. Due to the small sample size and concerns about reliability, we will be using SIPP data. • Family planning services- Maryland's Family Planning eligibility system of record is outside of CARES and the data was not readily available. • Other Medicaid section 1115 demonstration (e.g., childless adults)- Maryland's childless adult (Primary Adult Care program or PAC) system of record is outside of CARES and the data was not readily available. Also, because Maryland will be expanding, all 2 If SIPP results include conversions for applicants and beneficiaries, both should be included . Page 4

-i z 'Ito s:: ~ w 6 0 N 0 ~ s:: ~ )> 'U 'U ::0 ~ m c:J ~ ~ w i\3 ~ w m , , m 0 -i ~ 0 ~ ~ i\3 0 .:.. of these childless adults will be considered newly eligible beginning January 1, 2014. This conversion will not have an impact on the Maryland Medicaid program. • AFDC payment standard 7/16/1996- While this data is available in our CARES system, this conversion will not have an impact on the Maryland Medicaid program because Maryland currently covers parents up to 116% FPL. • Children under age 1, children ages 6 to 18, M-CHIP optional targeted low-income children (non-premium) & M-CHIP premium - Due to significant differences with the results from our state data conversion and the SIPP results, SIPP data will be used. For all conversions using state data, please provide the following information: Time period-Specify the time period of data that was used, for example, June 2011-May 2012. If a time period other than 12 months was used, please explain why below and summarize the methods used to determine that the time period is unbiased. Attach additional pages if necessary: A full year of data were used for all conversions (January 2012- December 2012). Sampling: Please mark this column yes or no. If yes (in other words, the analysis did not include all records in the eligibility group), please provide a detailed explanation below of the sampling approach that was used (i.e., simple random sample, stratified sample, etc.). Please also provide information about the total population and the number of records sampled. Attach additional pages if necessary. Net income standard- Please fill in the net standard that was converted for each eligibility group. This should reflect the bolded standard from the eligibility template that you developed with CMS. For conversions that were based on fixed dollar thresholds, please specify the net standard for each family size. You may use fewer or more family sizes than indicated in Table 1. For 1115 demonstrations, please enter a row for each MAGI-included 1115 demonstration group, specifying whether its Medicaid or S-CHIP. Income band used in conversion-This column is applicable only for the State Data method and should reflect the net standard minus 25 percentage points of FPL. For example, if the net standard was 120% FPL, the income band used in conversion would be 95% FPL to 120% FPL. For standards at or below 25% FPL, the income band will include all records-e.g., for a net standard of 18% FPL, the Page 5

-I z 'lj, s:: 9 w 6 0 N '? s:: s:: :l> "U "U ;o 0 < m I:J ~ w ;::; 0 ~ w m "T1 "T1 m 0 -I < m 0 0 ~ ;::; ~ ~ income band used in conversion should be 0-18% FPL. For conversions of fixed dollar thresholds , please specify the income band (expressed as a percentage of FPL) for each family size. 3 Converted standard for applicants-Please fill in the converted standard for applicants. Fixed dollar standards should be given in dollars for each family size. Converted standard for beneficiaries (if relevant)- If your state applies different disregards based on whether someone is applying or being renewed for coverage, and you are doing a separate conversion for beneficiaries, please provide. Fixed dollar standards should be given in dollars for each family size. Special note for premium payment groups: if your state charges premiums for any eligibility group, you will need to attach a separate sheet showing the MAGI Conversion Plan information requested for each income level used to determine premium payments. 3 See page 15 of How States Can Implement the Standardized Modified Adjusted Gross Income (MAGI) Conversion Methodology from State Medicaid and CHIP Data for more information on converting fixed dollar standards to FPL. http://aspe.hhs.gov/health/reports/2013/MAGIHowTo/rb.cfm . Page 6

-I z ~ s:: C? c..:> 6 0 N ? s:: s:: )> "'0 "'0 ;:o ~ m q ~ ~ c..:> i\3 0 ~ c..:> m "Tl "Tl m 0 -I < rn 0 ~ 0 ~ i\3 0 .j>. Coverage Category Parents and other caretaker relatives (mandatory under Section 1931) Parents and other caretaker relatives (optional under 1902( a)(10)(A)(ii)(I) Pregnant women, full benefits Pregnant women, pregnancy only coverage Children under age 1 Children ages 1 to 5 Children ages 6 to 18 M-CHIP optional targeted low-income children (non-premium) Optional reasonable classifications of individuals under age 21 State adoption assistance SIPP Results used (Yes/No) No N/A Yes N/A Yes No Yes Yes No N/A Time Sampling Period (yes/no) CY 2012, No January to December N/A N/A N/A N/A CY 2012, No January to December CY 2012, No January to December N/A N/A --- Table 1 Net Income (For State Data Converted Converted Standard Method Only) Standard for Standard for Income band Applicants Beneficiaries (if used in relevant) conversion % FPL % FPL % FPL N/A 116% 91 % to 116% 123% N/A N/A % FPL % FPL N/A 250% 259% N/A N/A % FPL %FPL %FPL N/A 185% 194% %FPL %FPL %FPL N/A 133% 108% to 133% 138% %FPL %FPL %FPL N/A 100% 109% %FPL % FPL N/A 185% to 200% FPL 211% % FPL % FPL % FPL N/A 116% 91% to 116% 123% N/A N/A Page 7

--; z '"' s:: 9 ~ w 6 0 1\.) 0 ~ s:: ~ ):> -u -u ;:o 0 < m 0 ~ w ;:::; 0 ~ w m "TI "TI m () --; < m 0 ~ ~ ;:::; ~ ~ Coverage Categor·y Independent foster care adolescents Family planning services Individuals needing TB- related services Other Medicaid section 1115 demonstration (e.g., childless adults) Separate CHIP • Children Separate CHIP • Pregnant Women Separate CHIP • Unborn child option AFDC payment standard 5/1/1988 SIPP Results used (Yes/No) N!A Yes N!A Yes N/A N/A N/A N/A Time Sampling Net Income Period (yes/no) Standard N/A N/A %FPL 200% Childless adults, 116% FPL N/A N/A N/A N/A N/A N/A N/A N/A Fixed dollar standards Family size 1 2 3 4 5 6 7 Add-on for additional family members if relevant (For· State Data Converted Converted Method Only) Standard for Standard for Income band Applicants Beneficiaries (if used in relevant) conversion N/A N/A % FPL N/A 212% N/A N/A % FPL N/A 123% N/A N/A N/A N/A N/A N/A % FPL by family Fixed dollar Fixed dollar size standards standards 1 Family size Family size ? 1 1 3 2 2 4 3 3 5 4 4 6 5 5 7 6 6 Add-on for 7 7 additional family Add-on for Add-on for members if additional family additional family relevant members if members if relevant relevant Page 8

--i z "*' s:: 1:? w 6 0 N 0 ~ s:: )> -o -o ::u 0 < m q ~ ~ w ~ 0 w m , , m 0 --i < f1:1 0 ~ 0 ~ ~ 0 ~ ~ Coverage Category AFDC payment standard 7/16/1996 Premium payment determination SIPP Time Sampling Net Income (Fot· State Data Converted Converted Results Period (yes/no) Standard Method Only) Standard for Standard for used Income band Applicants Beneficiaries (if (Yes/No) used in relevant) conversion Yes Fixed dollar % FPL Fixed dollar Fixed dollar standards standards standards Family size or Family size Family size 1 $165 % FPL bv Family 1 $187 1 N/A 2$292 size (for groups with 2$322 2N/A 3$373 fixed dollar 3$410 3 N/A 4$450 standards} 4$495 4N/A 5$521 1 5 $574 5 N/A 6$573 2 6$633 6N/A 7$645 3 7$713 7N/A 8$709 4 8$785 8N/A 9$766 5 9$849 9 N/A 10$826 6 10 $917 lON/A 11 $886 7 11 $984 11 N/A 12$946 Add-on for 12 $1,052 12 N/A 13$1,004 additional family 13 $1,118 13 N/A 14$1,063 members if 14 $1,184 14N/A 15 $1,124 relevant 15 $1 ,253 15 N/A 16$1,184 16$1,321 16 N/A Add-on for Add-on for Add-on for additional family additional family additional family members if relevant members if relevant members if relevant ill $68.70 N/A PLEASE ATI'ACH A SEPARATE SHEET SHOWING REQUESTED INFORMATION FOR EACH RELEVANT INCOME LEVEL USED TO DETERMINE PREMIUM PAYMENTS Page 9

--l z '*" ~ I? w 6 0 N 0 ~ ~ }> "0 "0 ::0 0 < m CJ ~ ~ w ;;::; 0 ~ w m , , m 0 --l < rn 0 0 ~ ;;::; 0 -1:> Coverage Category Pre-CHIP Medicaid as of3/31/97 Premium Payment Determination M-CHIP, 200 to 250% FPL M-CHIP, 251 to 300% FPL SIPP Results used (Yes/No) Yes(<1 , 6- 18) State data used for 1- 5 Yes Time Sampling Net Income Period (yes/no) Standard CY 2012, No <age 1: 185% January to December 1-5: 133% 6-13: 100% 14-18: 100% 200% FPL to 250% FPL 251 to 300% FPL (For State Data Converted Converted Method Only) Standard for Standard for Income band Applicants Beneficiaries (if used in relevant) conversion <age 1: N/A 194% 1-5: 108-133% 1-5: 138% 6-13: 109% 14-18: 109% Lower bound: 212% N/A FPL Middle bound: 264% FPL Upper bound: 317% FPL Resulting bands: 212 to 264% FPL; 265 to 317% FPL Page 10

-I z "*' ;;: ~ c..> 6 0 "' 0 ~ ;;: }> -o -o ;:o 0 < m q ~ ~ c..> i'3 0 ~ c..> m , , m 0 -I < rn 0 ~ 0 ~ i'3 0 .:. PART 1: EliGIBiliTY CONVERSIONS Alternative Method, additional information Please provide a summary of the alternative method and data source or sources used for income conversion, including how the method differs from the Standardized MAGI Conversion Methodology specified in the December 28, 2012 State Health Officials' Letter on Modified Adjusted Gross Income (MAGI) Income Conversion. Please include equations showing how the method is applied mathematically and a description of how fixed dollar standards were converted, if relevant. Attach additional pages if necessary. Please provide a description below of how your method meets the criteria specified in the December 28, 2012 State Health Officials' Letter on Modified Adjusted Gross Income (MAGI) Conversion: unbiased, accuracy, precision, and data quality. Attach additional pages if necessary. More detailed information abo.ut these criteria is available in the ASPE issue brief Modified Adjusted Gross Income {MAGI} Income Conversion Methodologies. 4 Unbiased: Across all eligibility categories, the method does not systematically increase or decrease the number of eligible individuals within a given eligibility group or systematically increase or decrease the costs to states. Accuracy: To the extent possible, the method minimizes changes in eligibility status by minimizing losses and gains in eligibility for a given category of coverage. 4 See http://www .shad ac.org/fi les/2. %20ASP E%20 Brief%2Q~%.20MAG I %201 ncome%20Conversion%20Meth odologi es%20( March%202013). pdf . Page 11

r --l z 'It :s:: ~ (.,.) 6 0 "' 0 ~ :s:: ~ )> ""0 ""0 ::0 0 < m 0 ~ ~ (.,.) i'3 0 (.,.) m -n -n m (") --l < m 0 ~ 0 i'3 0 .,. Precision: The converted standard must be stable and repeatable. In other words, if the methodology to arrive at the converted standard were repeated, it would arrive at the same result. For example, if a sampling methodology is used, the sample size must be large enough to ensure that the conversion method, if calculated on another sample, would in general yield the same converted standard. Data quality: The data used are representative of the income and disregards of the population so as not to bias the converted standard due to poor data quality.-- - - - ---------------------------------------- Page 12

Table of Contents State/Territory Name: Maryland State Plan Amendment (SPA)#: 13-0021-MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan - Attachment 1- Maryland HBE- CMS Alternate Application for Health Coverage

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 -· CMS CENTERS FOR MEDICARE & MEDICAID SERVICES Region lli/Division of Medicaid and Children's Health Operations SWIFT #021120144010 FEB 1 2 2014 Charles J. Milligan Jr. Deputy Secretary Health Care Financing Maryland Department of Health and Mental Hygiene 201 West Preston Street, Room 525 Baltimore, MD 2120 1 Dear Mr. Milligan: Enclosed is an approved copy of Maryland's State Plan Amendment (SPA) MD-13-0021-MM2, which was submitted to CMS on November 15, 2013. SPA MD-13-0021-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Maryland's Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013. The approval of SPA MD-13-0021-MM2 includes full approval ofyour state's alternative single streamlined online application. Enclosed is a copy of the following S94 state plan pages and attachments to be incorporated within a separate section at the end of Maryland's approved state plan: • S94, pages S94-1 and S94-2 • Attachment 1- Maryland HBE - CMS Alternate Application for Health Coverage CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Lieutenant Commander Andrea Cunningham at (215) 861-4325 Enclosure (b) (1) (A), (b) (b) (1) (A), (b) ( (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /s/

I I I MD.0509.ROO.OO- Oct 01 , 2013 Page 1 of2 Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Maryland Transmittal Number: Please enter tile Transmittal Number (TN) in the format ST-YY-0000 wit ere ST= tile state abbreviation, YY =tile last two digits of t!1e subm!_!_S.i.f!_'!_lea~! ll!!lf 0~0-= a four digit number wit It leading zeros. Tile dashes must also be entered. MD 13-0021 Propos~~~_!~~~!iy~ ~lite. . 10/01/2013 (mm / dd/yyyy) Federal Stat!Jte!Re.gu_!:l_~i_on C!.!..l!!!on 42 CFR 435, Subpart J and Subpart M Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment $0.00 $0.00 Amount Attesting that the state meets all the requirements of 42 CFR 435, Subpart J and M. Eligibility applications are included. 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: Authority delegated to Deputy Secretary for Health Care Financing, Charles Milligan. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Molly Marra Nov 21,2013 Nov 15, 2013 (b) (1) (A), (b)

Attachment 3.1 G Medicaid Eligibility OMB Control Number0938-1148 OMB [{] The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and ./ furnishing Medicaid. Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with !ZJ section 1413(b)(l)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section l413(b)(l)(B) of the !ZJ Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the D agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. 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 D approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. !ZJ 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. 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: r. Yes (' No TN No. MD-13-0021-MM2 Maryland Approval Date: 0211212014 Effective Date: 1010112013 Page 1 of3

Attachment 3.1G Medicaid Eligibility Indicate the other electronic means below: Name ofMethod Service Access and Information Link Description SAIL is a web-based screening and application tool that will allow Maryland applicants to complete the following: Am I Eligible? - A series of questions to help you decide for which social services benefits you and members of your family may want to apply. Start an application: Apply on-line any time of day or night for the following programs: Food Supplement Program, Temporary Cash Assistance, Temporary Disability Assistance Program, Medical Assistance (Aged, Blind, Disabled only), Medical Assistance Long Term Care, Maryland Energy Assistance Program, Electric Universal Service Program, Child Care Subsidy Program. The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility [{] groups listed below at locations other than those used for the receipt and processing of applications for the title IV -A program, including Federally-qualified health centers and disproportionate share hospitals. Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross [{] income standard are performed as follows, consistent with 42 CFR 435.916: [jJ Once every J2 months [jJ 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 [jJ information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. • !!] Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross • income standard are performed, consistent with 42 CFR 435.916 (check all that apply): IZJ Once every 12 months D Once every 6 months D 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. TN No. MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013 Page 2 of3

Attachment 3.1 G Medicaid Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of infonnation unless it displays a valid OMB control number. The valid OMB control number for this infonnation collection is 0938-1148. The time required to complete this infonnation collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the infonnation collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this fonn, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013 Paj;(e 3 of3

Supplement 1 to Attachment 3.1 G (\j\ 2 ,' MARYLAND HBE - CMS ALTERNATE APPLICATION FOR HEALTH COVERAGE Sc"l') c ["'NT I"'' 1 P1'U· '[{ [} .. , . l 1::'[ 0 Hf C'llA R "fS' .._ _ \.f~ L~ L- h . . Ll :, 0 t1 (. r' __ , j n . .. ·. . . TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 1010112013

Supplement 1 to Attachment 3.1 G Contents 1 Section 1- My Account ......................................................................................................................... 5 1.1 Create Account .............................................................................................................................. 5 1.1.1 Flow Charts ............................................................................................................................ 5 1.1.2 MHC Landing Page ................................................................................................................ 6 1.1.3 Check the Cost of Health Plans: Getting Started .................................................................. 7 1.1.4 Purchase Plans With and Without Assistance: Getting Started ............................................ 7 1.1.5 Create a User Account .......................................................................................................... 7 1.1.6 Client Login ............................................................................................................................ 8 1.1.7 Login from MHC Landing Page .............................................................................................. 8 1.1.8 Purchase Plans with Assistance: Getting Started with Application ...................................... 8 2 Section II -Privacy ................................................................................................................................ 9 2.1 Flow Chart ..................................................................................................................................... 9 2.2 For Myself and/or My Family ........................................................................................................ 9 2.3 Authorized Representative or Assist or ....................................................................................... 10 2.4 Privacy Act Statement ................................................................................................................. 10 3 Section Ill- Getting Started ................................................................................................................ 11 3.1 Contact lnformation .................................................................................................................... 11 3.1.1 Flow Chart ........................................................................................................................... 11 3.1.2 Authorized Representative Contact Information ............................................................... 11 3.1.3 Assistor Contact Information .............................................................................................. 14 3.1.4 For Myself and/or My Family Contact Information- Primary Applicant ........................... 16 4 Section IV- Assistance with completing the application ................................................................... 22 5 Section V- Help Paying for Coverage ............................................................................................... · .. 22 5.1 Flow Chart ................................................................................................................................... 22 5.1.1 Pre-Screening Calculator ..................................................................................................... 22 5.1.2 Tax Filer lnformation ........................................................................................................... 23 6 Section VI- Tell us how many people are applying for health coverage ........................................... 24 6.1 Flow Chart ................................................................................................................................... 24 6.2 Other Household Members ........................................................................................................ 24 6.3 Household Member Details ........................................................................................................ 25 6.4 Relationships ............................................................................................................................... 27 S94 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Page 2 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G 7 Section VII- Tell us about each person .............................................................................................. 29 7.1 FlowChart ................................................................................................................................... 29 7.2 Primary Applicant- Applying for Coverage ................................................................................ 29 7 .2.1 Document Types ................................................................................................................. 33 7.3 Primary Applicant- Not Applying for Coverage ......................................................................... 33 7.4 Existing Coverage ........................................................................................................................ 34 7.5 Supporting Documents ............................................................................................................... 34 7.6 Married Couple Filing Jointly ...................................................................................................... 42 7.7 Dependents ................................................................................................................................. 43 8 Section VIII- More about this household .......................................................................................... 44 8.1 Additional information for all Applicants .................................................................................... 44 9 Section IX- Expedited lncome ............................................................................................................ 46 10 Section X- Current/monthly income .............................................................................................. 46 10.1 Flow Chart ................................................................................................................................... 46 10.2 Income Information .................................................................................................................... 46 10.3 Enter Income Details ................................................................................................................... 47 10.4 Income Deductions ..................................................................................................................... 49 10.5 American Indian/ Alaskan Native Excludable Income ................................................................. SO 10.6 American Indian/Alaskan Native Income Details ........................................................................ SO 10.7 Summary .................................................................. , .................................................................. 52 10.8 Annual Income ............................................................................................................................ 54 11 Section XI- Discrepancies ............................................................................................................... 54 11.1 Income Discrepancies ................................................................................................................. 55 12 Section XII - APTC program questions ............................................................................................ 56 12.1 Additional Insurance Assistance Information ............................................................................. 56 12.2 Health Program/Plan Coverage Information .............................................................................. 57 12.3 Employer Sponsored Coverage ................................................................................................... 58 12.4 Additional Information of Employer ........................................................................................... 59 12.5 Employer Plan Coverage ............................................................................................................. 60 13 Section VIII- Medicaid & CHIP specific questions .......................................................................... 62 13.1 Additional Information for Medicaid/CHIP Applicants ............................................................... 62 13.2 Unpaid Medical Bills Details ........................................................................................................ 63 S94 Maryland- HBE CMS Alternate Application For Health Coverage Page 3 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 0211212014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G 14 Section XV Review & Sign ............................................................................................................... 64 14.1 Submit Application ...................................................................................................................... 64 14.2 Submit Application Renewal ....................................................................................................... 66 14.3 Submit Application Confirmation ............................................................................................... 66 S94 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Page 4 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachrpent 3.1 G 1 Section I - My Account 1.1 Create Arcount 1.. 1.. 1. Flow Cha.rts MARYLAND HEALTH CONNEcnON {MHC) LANDING PAGE CHECK THE COST OF HEALTH PLANS PURCHASE PLANS WITHOUT ASSISTANCE i PURCHASE PLANS WITH ASSISTANCE CHECK THj: COST OF HEALTH PlANS --------~ ______ ] -----------------·-··-·--·---·--------·--------·----·------·-------·-------------- PURCHASE PlANS WITHOUT ASSISTANCE 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021 -MM2 Maryland Page 5 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

PURCHASE PLANS WITH ASSISTANCE GETTING STARTED AUTHORIZED REPRESENTATIVE 1..1.2 .MHC Landing Page !NF..F.OH<:LF " ~~-·t;{: l C•:•l fj•:·•~C 1·:• ;;t_:, :.f p:3 r,A . ~~il::; tr~ :.s··· <:';..::::p~,::; > Supplement 1 to Attachment 3.1 G FOR MYSELF AND/OR FAMILY ;;~._: .. ..-.;,;:,~ :.::±.:_:y~.,t!~~-::~e~,;._. ~~,, ... ? ... ·---~-:> .. tnancl.ill ~ - , .... ,a:-: <·· ---p~o~e<- !~~~~~-~~~~--~~~~~~ --- ~ . Can : :e ".: :":;r,~o:;: l~( .. 594 Maryland- HBE CMS Alternate Application For Health Coverage Page 6 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

1.1.3 Check the Cost of Health Plans: Getting Started .,.. Getting Started To get started, please choose one of the options below: ,-:- Create an ~ccount. Creating youc own atcount wll tet ~save what you are doing and. CQfT'Ie back I:J il later () log in log Hl t you ai"ead;- have an account ·~·· Continue without togging ln. Conln1ue without creating ~n Keount Qr logging in 1.1 ,4 Purchase Plans With and Without Assistance: Getting Started <4 Getting Started Before star110g lhts process, you must create a new account or log tn to an account I hat you already have To get started, please choose one of the options below. \. · Cr..lte an a~ceount. Creming ~ o•,..,'fl accCil.Wlt wtH let you save your wQO( and retum tCl rt later c~ log in If you alread:l ha\o"e an <.r.C:!)Uf\( 1.1 ,5 Create a User Account r Create~ a tJser /\ccount Supplement 1 to Attachment 3.1 G N:exl :..t··-:: .... In order to set up a user account. please enter your details below. Yow· user account will let you save vour application and wme bat~ tort later. You will also be able to thecK the status of your application after you submn n. If you t·,ave quest1ons aoout uealmg your use•· account please call ;he CIJstomer serv1te Cen;er al ~ 53 -1-4323000 Personal Details Rrst Name * Email User Name and Password User Name~ PassNord ~ Re-t'tpe Password :~: Password Hint Question .t. Ansv.rer -t Mcther"s maiden r.ame Last Nan1e -~ { .) Please check the box to let us know that you have read and agreed to the usage condlloos. !Jones 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 7 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

1.1.6 Client Login r:J Client Login Login to ~'ou:· account Your Logm Deta11s Pl€3${1 .:;>:l::€:r rcc.::- •.:-::er 1':3:';;1€: ~:"ld p~~S:Y;'Ofd c:·:d ch:k thi: N?.'d. bt:tt1::r. ro '.C:":!Jr~:J€. IJser Nltme: ~ • ...;c:::~ !.:;~ 3:i~lill->n..:.a Wtl"! fUut l-l i3lL~ Car<J • ".f.Cil IC. ::Uf~3&-l tool~ll J:lans WlttoOOI ;3Si£1.lt'c.t · Ct.e~ t'lf C')Sf o: MarJI ;>i.."lllS · '"f~i'l-:t a~1 ~m;!&!~r·!ponl~O.!hnl!t. ~la!l . . 64'p/;·f~t ~n -!1!::-r- ~flo:n Supplement 1 to Attachment 3.1 G Purchase Plans with Assistance: Gt:~tting Started with Application 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Page 8 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G 2 Section II - Privacy 2.1 Flow Chart APPLYING ON BEHALF OF SOMEONE ELSE APPLYING FOR MYSElf AND/OR MY FAMILY HOUSEHOLD INFORMATION 2.2 For Mys(~[f and/or My Far~tHy "" Before We Start Please read the tntormatlon below and ctiecr. the box to snow your agreement Household Information We"ll keep your information private as reqUired by law. Your answers on this rorm will only be used to detemline eligibili~; for health insuranee or help pa)1ng tor health Insurance •.ve•n check your answers using information in our ele<tromc databases and the databases o! our partner agencies n the lntom1ation doesn't match. "'" may ask you to send us proof This application doesn't ask questions about the househOld med~al history Household members 1'111D dont want insurance won•t be asked quesMns abOUt Citizenship and Immigration. Important: As part ot the appiK:aMn process. we may need to retrieVe inlormatlon aboullhe household !rom other government agencies Hke IRS. Social secunly Admlmstration and the Depanment o! Homeland Setu~/ vve need this inlormation to check the hOUsehOld eligibility lor hea~h Insurance or help paying tor heallh insurance. 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland !lex! Page 9 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G 2.3 Authorized Representative or Assistor * Bef(xe Vl/e Start Please read the intormation below and c.r,eck the bm: 1o shO\V your agreement Household Information We'll l:eep your lnfonnation priVate as required by law. Your answers on tills rorm "'ill only be used to detennlne eligibility for health Insurance or help paying for health Insurance. 'Ne'll ct.eck your answers using Information In our electronic databases and tile databases o; our partner agencies. If the information doesn1 match. we may ask you to sen<l us proof. Important: As pa11 ot the apphcaUon process. we rnay need to retrieve antonnat1on about the household !rom other government agencies like IRS. SOCia~ Secunty Administration and the Department or Homeland Securi~J- We need this lnfonnatlon to checK the household eligibility lor health Insurance or help paying ror health insurance By checking this box you are confirming that the applic;ant has 9fi10ted you permis:5ion to enter information on their behal" and that you will not disdose that information to anyone el-ie without the applicant's permtssk>n. 2.4 Privacy Act Statement tlext MARYLAND HEALTH BENEFIT EXCHANGE PRIVACY STATEMENT Thank you for visiting a website published and managed by the Maryland Health Benefit Exchange (MHBE), a public corporation and unit of State government. This statement applies spedfically to www rnar \'l¥;dtt~~ithwnnecUsm qcw. Information Colled:ed and stored Automatically When you browse this website, read pages, or download information, certain information about your visit is automatically gathered and stored. This information does not identify you personally, and indudes the following: The internet domain (example: aol.com) and the IP address (the number automatically assigned to your computer when surfing the Web) from which you access our portal, The type of browser and operating system used to access our site, The date and time you access our site, The pages you visit, The address from whidl you linked to our website. This information Is used to make this website more useful to visitors, to learn about the number of visitors to our site, and the types of technology our visitors use. We do not track or record identifying information about individuals and their visits. Cookies This website uses "temporary cookies" to track user navigation in order to make the portal experience more useful. A temporary cookie is erased when the user doses the web browser. The "temporary cookie", also called a session cookie, Is stored in temporary memory in the form of a text file on your computer, and is erased after the browser session is ended. No identifying user information is collected and stored on other computers anywhere. We store no personal information based on your visit to our website. General Privacy Polley It Is our policy to presetve the privacy of personal records and to protect confidential or privileged infmmation. Such Information will be disdosed publidy only as required by the Public Information Act or as necessary or permissible to carry out offidal duties. Under State law, these polides do not apply to information gathered for ce1tain specified purposes, sudl as the investigation of a possible violation of the law. If you have any questions about these privacy polides, please e-mail them to TOO Privacy Polley Changes O!anges to our websites may necessitate changes to our privacy statement Notification will be posted on this website in the Privacy Notice link. The information contained in this privacy statement applies only to ,~ww.matylandhealt!wanneLtion.ucv 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-1 3-0021 -MM2 Maryland aose Page 10 of 66 Approval Date: 0211212014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G 3 Section III - Getting Started 3.1 Contact Information 3.1..1. Flow Chart APPLYING FOR MYSELF AND/OR M Y FAM ILY ! HOUSEHOLD INFORMATION 3.1..2 Authorized Representative (ontact Information ... G~J:lS~tarted > ···· i .. < ······ Values (lhppll~able) •··· •••••• Banner let's get started with your application In order to evaluate the eligibility for insurance assistance an application is required to be completed and submitted. Information on who is applying for coverage determines how the application information is captured on subsequent pages. Please select an option from below which will be used to drive the information capture. I am applying For myself and/or my family As an individual acting responsibly on behalf of someone else As an authorized representative Cluster Name: Application Filer Details You have indicated that you are applying as an authorized representative and not yourself. Before we ask for their information we need to know about some basic details about you. Title Dr. Miss Mr. Mrs. Ms. Prof. 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Page 11 of 66 Approval Date: 0211212014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G Gettmistarted .• • I> . L V~lues (If appl~ble) .t Suffix Esquire Junior Senior First Second Third Fourth Fifth First Name Middle Name last Name Cluster Name: Your Address Apt/Suite Address City State Alabama ~Wyoming Zip Code County list of all the counties by state wise Cluster Name: Other Contact Information Preferred Contact Method Email Post/Mail Home Phone Number Work Phone Number Cell Phone Number E-mail Address Cluster: Authorization Information Enter the date the applicant authorized you to apply for coverage on their behalf. Enter the name of the applicant that authorized you What has the applicant authorized you to do? Complete and submit renewals Sign the application on the applicant's behalf Receive copies of all notices and communications Act on behalf of the applicant on all other matters Do you belong to an organization? No Yes (If the dropdown value forthe field 'Do you belong to an organization?' is 'YES' the following fleld(s) appear) Please enter the organizational details Name Identification Number 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 12 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

By checking this box you are agreeing that you will adhere to all relevant State and Federal laws concerning conflicts of interest and confidentiality of information, including the following provisions in the Code of Federal Regulations: Chapter 42, part 431, subpart F; 42 C.F.R. 447.10; and 45 C.F.R. 155.260(f). By checking this box you are confirming that the applicant has granted your permission to enter information on their behalf, that you acknowledge you are responsible for providing information and communicating to the same extent as the applicant would be for the tasks you checked above, and that you will not disclose that information to anyone else without the applicant's permission. 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G Page 13 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G (A ;:'; -~-~ t.;. ~-·~:~~~,- !:~~ -:-:->:~·:t.·~ ~":> ;;:;;,, :~':-;$o- A ;.~:~:;:.•:-'<} -~:·,~XX'·~·:: ~- i'":.;:-.;·:~~ ~{; ~(,· :· .• ~-:-::~,:v:~~ r.<-.<- ~ ~-~.-::·:·~~~--~ ::·~y:':'::X..-:~>: -:-~ '~:':~---~ ->:"::Xi~:.;::-; -: ·: ::•e({,:.:}:- .;:v:~:-·.·.;:-.~:~ ~-;u, ~:·.>o: .~.;:::~~~-~t-:::~ .::;1'-~, .-:-.g·.;-:i :$ ~:;.~~:-::;e.;.;:,~ : : -::;.~~'<;.;~.:~ :'·A·~~- ~·::::-~;.:' ~.:-:--..',' -~'· ;:;X:v:"~ ... ":: X:·;..:;.: ,...:l'-v: ':-:> :» :.:~>i :~ .,.».~ :~.s ·=~~:•.: . .K::v ,~:ll;..,•:: (' ~ .,:u"'~4'.1'~n.~~mr f~- .. -· .. r,·,: ~· ~~>(.l()~;v.~ f<: '$.1.~~~~.,:: ~~~ :.:J. s~"':' !'::-:;{" ·4J.; I..~ M:t-r.t'lt:."M ~~'Yf-~~.11: ./ Yaur A.d drnt Other Cont.tct lnform•tlon Avthofization lnfatmaflon tAn~~ IV~ s.:mrn:t r9t 'Wf..,'~~ s:~ ::c:~ ~!f':f~ oY.•>."l <4> =~~·: ~JJ's4i( ;~tr:~ t• . .,.;.:oN (0:itf1'c>lvtl f ~lf. cl if:'(t~vr:~:S:.1:1fG !~K$~~t~'S ::·~ ,\. ; 1 .:4>~:-c-f~f:dN! ..JE.'VI>:::iV>:W·:.:t: :;tt ... oo: II (.)F,c.!"~· r'~ :~· 0t·:b~ =~--~ :-:• :--:-~ <-=+ .c:;n ..:-:>'1 :•vtt \'+.( ..,.,~ ~::>+··-:- t~ ..:: ' ":•:..~':t f.<o)!-l- l':l"-t f<-~<·~ :·:x.-..:-: <N:<+l'!~~ :::.o.~~=1> f.t :.-.:~ <·:< t:·.·H(-~:~-:':-:c<1:f::tf :::· :•,•~ ·-..-:-:•:·~<· . ..-..:: .... ::-:::_) ~~ !: .... ~« ... ,~ ~·e.Y·}:«:~ ~-= ~v ~·.-:-:u ·1-! ::~ .:-:·!"1: '"'11-:"!-:•""''»7.~: =--~~~9--·~;,jc).-"'t .. . ~. ~~..:":;.., It)::.:* .~:.c. ~~- :lo~ .:·, < j. lo: ~=·~-!~·=:~/: -J»· ~N-c~i :'}l ~::-:..;,a f!•X ~~x <<-:i:(:">"SS '::-t: :,i:f" :o;;.';:· :-:-:-J:~ ~~~·~It<-: :->~~: : :X·• •=~·~x:'l t-:- N:l",--: .;:,.x-:---.,rx.:-: «·. ::t.l-~ · !x-:-r.:( :)..~· .,,x, lf':~-:-~:w:):~ v..:-: '1::-- ~.:·~:-:-:·:~«· f:.:- :.:•'l"..-11':<:,;, <~::<:"'~»:: -tN: ·~xN: ~x-x:~=>:-::_: :,;. :..' (' '!<.Y.·~· :co~~--.: ~-~~~- ~t.;-Y.;:.~., ~"":'-~ ~ ·~ ~= v. ~.< '!l"'dt"~:'~ .:-~ ~~Xu 1-. ~~-.;; t~,..: ,.~ .. -:-~·=· :-~;-. ·1-.%•:~~ ~~-:Y. :i"l>X<:";¥.:<'(. :.;. :t-••1-:·('. •·:<.;: .-~:-;.: .. ~ ~-.e:- ~;:f•=·.:.s-::r~ t .:-"':'t:·.,;...;..;.s· 3.1.3 Assistor Contact Information Gettins started values (If applicable) Banner 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 14 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1G 6ettiJli$tarted ···•••·· ····· ... .. ········ .. Values {If appllcilbte) < .···.··· \ let's get started with your application In order to evaluate the eligibility for insurance assistance an application is required to be completed and submitted. Information on who is applying for coverage determines how the application information is captured on subsequent pages. Please select an option from below which will be used to drive the information capture. I am applying For myself and/or my family As an individual acting responsibly on behalf of someone else As an authorized representative Cluster Name: Application Filer Details You have indicated that you are applying on behalf of someone else and not yourself but before we ask for their information we need to know some basic details about you. Title Dr. Miss Mr. Mrs. Ms. Prof. Suffix Esquire Junior Senior First Second Third Fourth Fifth First Name Middle Name last Name Cluster Name: Your Address Apt/Suite Address City State Alabama ~Wyoming Zip Code County list of all the counties by state wise Cluster Name: Preferred Method of Communication Communication Preference Email Post/Mail Home Phone Number Work Phone Number S94 Maryland - HBE CMS Alternate Application For Health Coverage Page 15 of66 TN No: MD-13-0021-MM2 Maryland Approval Date: 0211212014 Effective Date: 10/01/2013

Ciettinlfstarted ···. ._. Vc!l~es (If applicable) ;. .... Cell Phone Number E-mail Address By checking this box your are confirming that the applicant has granted your permission to enter information on their behalf and that you will not disclose that information to anyone else without the applicants permission AppUuDon Fifer Dtttallr. Othe,. Contact mfotmt~tton R'i <hc•dt~~<i,l tlo~ OOX\"<40-o IHP.MY6n~f>.J :h.;:M ~ ~;r"A.fl~ hoi..'$ 9»•m:C">J "fW' f.._"11'::-:'<~):~ ;,.~ ~r~ •"'f:".<m.Y.:<~> !:ti ~'~'1: ~h!-~ bt>:l:..-,:~ :HKi :tut 'f:>:U ~?i r1tl( >..~$.:::~ :.1'1At a.~~::ui~ :;; .Nt-:J~W!I !'!f~ •~<.hnt~ ~t> :sr.}):ICJI~t'~~ ;~~1:..•.~ '·' 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G ;... ... - Page 16 of 66 Approval Date: 0211212014 Effective Date: 1 010112013

Please enter your personal details below. You will be designated as the primary contact for the application. If you choose to include yourself in the application for coverage, the information you provide will be used to verify your identity, income and citizenship status. You will also be designated as the primary applicant. Suffix First Name Middle Name last Name Date of Birth Sex Your address is required in order to determine your eligibility to use Maryland Health Connection and also so that we can contact you with regard to any decisions we make about your eligibility. Do you have a fixed address? the Fixed Address field is 'NO', the Are you a Maryland resident? If you do not have a fixed address, please choose a local health department based on the county you spend the most time in. Dr. Miss Mr. Mrs. Ms. Prof. Esquire Junior Senior First Second Third Fourth Fifth Female Male No Yes No Yes 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G Page 17 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

addre~~is 'YES', the ng Address field is 'NO', the We need to know the best way to contact ou about this application. You may receive notifications by mail, email or phone Preferred Contact Method Supplement 1 to Attachment 3.1 G · Yes List of all the counties by state wise Alabama ~ Wyoming List of all the counties by state wise No Yes No Yes List of all the counties by state wise Phone Email Text Mail 594 Maryland- HBE CMS Alternate Application For Health Coverage Page 18 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G Preferred language Type E-mail Address American Sign Apache Brazilian Portugese Cambodian Cantonese English French German Irish Italian Japanese Korean lao Navajo Russian Simplified Chinese Spanish Traditional Chinese Vietnamese Business Fax Mobile Other Pager Personal Business Fax Mobile Other Pager Personal Do you want to find out if you can get help paying for your own No health insurance and health benefits? ~ Yes 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021 -MM2 Maryland Page 19 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

h"t ·~~ ~l':ij (S-A 'ill~;~ St..'l~"' -~~t/ tl:':4 ~VI' fl(f'I'K11:4~ a: U:1HI:: t>: thft Mol:\."\tMi 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G .... Page 20 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

ADDRESS LOGIC 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G Page 21 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G 4 Section IV -Assistance with completing the application 5 Section V- Help Paying for Coverage 5.1 Flow Chart HOUSEHOLD INFORMATION 5.1.1 Pre-Screening Calculator Estimate how the Health Refom1 Act may affect -ycu or your household Adults in household Children under 19 in houser.old Total annual household income Is an~one in the household pregnant? INCOME INFORMATION Based on ~our 3flnuaJ househesld income and household s1ze. you mar oe eligible tor Medicaid. Based on your annuat household tncome and househoh:J siz.e, )·our ct.ild{ren} younger than 19 rears old may be eligitle for Medicaid. *Your 3\o'allam9 health options are subject to change D:ased on the accurac{ of the Information you entered 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 22 of66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

5.1.2 Tax Filer Information We need to know who in your household is a 'tax filer' so we can figure out whether you qualify for help in paying for coverage. We've listed the members of your household below. Please indicate which of them will be filing taxes. INCLUDE yourself if you plan to file taxes, your spouse if he/she will be filing jointly with you OR will be filing his/her own form, your children IF they will have to file their own taxes, and any other dependents IF they will have to file their own taxes. DO NOT INCLUDE your children if they will not need to file their own taxes or any other dependents if they will not need to file their own taxes. If anyone in your household expects to file taxes this year, please select them below Please choose the ta< filers in the househ:>ltl Supplement 1 to Attachment 3. 1 G We need to know who ln your household is a 'tm< filer' so we can figure out whether you qualrfy for help ln pr~y;ng for covernge. We've listed the members of your household 0 below. Please 1ndi~te which of them wtH be tiling tmces. INCLUDE yourself if you plan to file tllxes, your spouse if he/she will be filing jointly wm-t you OR will be fi~ng his/her own form, your chlldren IF they wal have to file their own taxE!s, and any other dependents IF they wl~ have to ftle their own taxes. · oo·NOT INClUDE your children If they wlll ·not needlo · f~e thelnwm· t"""s or any other dependents ~they will not need Wflle their o•m taxes. If anyone in the household expects to Hie ta<es this yeac. please select them below ,·j , t· Jerry C1 Save & Exit 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland • B;Jck Page 23 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G 6 Section VI -Tell us how many people are applying for health coverage 6.1 Flow Chart HOUSEHOLD INFORMATION INCOME INFORMATION 6.2 Other Household Members •':\ Other Household fv1embers In order to properl'f delerm1ne your eligibility we need to know about any other people 1n the household ·.· .. :,. , . fndude your spouse, your children Under 21 who live w1th you, yOur unmcriied. partner who needs he~tth coverage, anyone "you indude on your tax return, even rf they don't live a wtth you and/or anyone else under 21 who you teke care of and liVes \\rith you. Don't indude your unmarned partner who doesn't nee<J health coverage, your unmarried partner's ch&dren, your pll:ren(s who ltve with you .• but file their own talx return (ff you're over Zl) and/or other adult re~tlves who file their own tl!:x return. Is !here anyone else In the household? .• , --Please S€1e<t- save&<llit S94 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Next Page 24 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

6,3 Household Member Details Please tell us about the next person in your household by filling in the information below. You may be asked more questions about this person on the next screen depending on whether you wish to find out whether you can get help paying for this person's health insurance and health benefits. Title Suffix First Name Middle Name Last Name Date of Birth Sex Does this person live with you? (If the dropdown value for the Live with you is 'NO', the following field(s) Is this person a Maryland resident? 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G Dr. Miss Mr. Mrs. Ms. Prof. Esquire Junior Senior First Second Third Fourth Fifth Female Male No Yes No Yes No Yes Page 25 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Do you want to find out if you can get help paying for health insurance and health benefits for this person? 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Yes Supplement 1 to Attachment 3.1 G Page 26 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G ~ Household rv1ember Details Please provide dela11s or I he nexl household member. iJ Pia.::s2 1 ~:: as ol::c:.:~ :!·:-:: r:ex: ~~rE·!·: i:'l ~ -=-t:r t:l"'useho:d Ct f:li:r:·~ ::-: tM· :r:fo:-r:·: ::tio:<~ t:elow YN: :Y:C:~· t-:: C:Ha::: !':":C:e ~t.:est:-:· :·::: <=~·;-l.lt :t.i::; :::..:!::;-:::: ·:·r: !he r.e;J s~·eEn ·1::::- ~::·~:r.~ O:'l._..~t:-:::!t:er ~-c:·~ w:~t: ~~ f::·::! >:·ll.t <"l: .. ::?!t:o:-r :: ... ;:J :·.a:l ):&: r1'.!b:· N~~:I:-::J t~'' •=~='3 t::~fs~rf~ h~a::t. ::·::::::·::::::1? :.;.:~:;~;or.:: :-o?r.-:-t:~s Details Title First Name ' • '{; Middle tlame Las! Name • Sheen ! • ?·· Date or Birth • Sex ·• ffe;,~--;---------:1 : ? :_ _ ______________ ...__: Does !his person live wnh you? •· Does this person have a fu<ed address? • Address ... 100 City lip coae •· Do you wanllo finO oul 1f you can gel help pa)•ing for healltrinsurance and health benefi1s ror this person? • Sa'le&Exit 6.4 Relationships ~ --Please Select·· Yes .~!!SUite ·· State• County - Please Select- In order to determine eligibility for medical insurance assistance, we need to know the relationships of all individuals in the household. Please select the most appropriate description of the relationship between each individual. S94 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland [···-·-·----·--·-·--·-··--...,-·: --Please Select-· ; • : ~--·-···-··· ·-- -----------·-·- ····· -·········------:.. ... ..; 1/1!1980 ........................... -...• ·t; Uext Page 27 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Relationships Are they also a non-parent caretaker of this person? 0 Relationships Gettng Started $ Please provide info;ma~k.'fl abcut househok:l member's retaflOnsh!pS Appfleant Details l-· tr Supplement 1 to Attachment 3.1 G Is Unrelated to Is the Appointee of Is the Appointer of Is the Aunt of Is the Child of Is the Cousin of Is the Foster Child of Is the Foster Parent of Is the Grand Child of Is the Grandparent of Is the Great Aunt of Is the Great Grand Child of Is the Great Grandparent of Is the Great Nephew of Is the Great Niece of Is the Great Uncle of Is the Guardian of Is the Live in Attend of Is the Nephew of Is the Niece of Is the Orphan of Is the Parent of Is the Person Cared for by Is the Sibling of Is the Spouse of Is the Uncle of ADditional HousehQd lnkKmaUon @( :J') H"!c·r :c· !':<·l~,;·.);f .. ) O:~J:::I:t:·!~' :':~"r:i·:a: :···r.t''·>:":·:~ ·>!':·:~:;:r .. :<· .. ,~:":<·~!':I:'!~'··>~.:~~ t~~:~ -:-:-::-b:r·<: -:-! ,::-:: 1::-~:.:<l!J:'::~ :r. :r.:o: :-:~··J :><:r. :t:-: P:<··>!'·: ::-~:c .. :t::'<-~ ;-:r .. ,~: a~·=H· p :t;;::<:· ":E~::ts:-:-·. :~:::---~ :~ : ~:-·>:'::Of:i::· :O::!~f-.;!': ~3-;!': I:':,::;,;(~IJ,,: A<klltioflallncorne InformatiOn Swnmary Veriftcauon summary Mary Are you also a pnmary caretaf\er of lllls person? 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland """' Page 28 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G 7 Section VII - Tell us about each person 7.1 Flow Chart HOUSEHOLO INFORMATION : INCOME INFORMATION 7.2 Primary Applicant- Applying for Coverage The information gathered in this screen is the same information that is gathered for all household members who are applying for coverage. 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021 -MM2 Maryland Page 29 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

We need Social Security Numbers (SSNs) for anyone who wants coverage. We use SSNs to verify citizenship. If someone doesn't have an SSN, visit socialsecurity.gov or calll-800-772-1213. TrY users should calll 800 325 0778. Do you have an SSN? · you have an §SN? is 'No" the (If the dropdown value for Have you applied for SSN? is 'No" the fol Reason why you don't have an SSN No Yes No Yes No Yes Can be 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G Page 30 of66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

the field liS National is 'NO' the lawfully present is 'YES' the National is 'YES' the If the member is a female over the age of 13 regardless of whether they are an applicant or not the following questions appear. Yes No Yes No Yes Supplement 1 to Attachment 3.1 G Certificate of Citizenship 1-551 (Permanent Resident Card) Naturalization Certificate Passport Is <name> currently pregnant or gave birth in the last 3 months? No is a the field pregnancy is 'YES' the is a between the ages of 18 and ~2 and insurance the following questions Yes No Yes No Yes 594 Maryland- HBE CMS Alternate Application For Health Coverage Page 31 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G .; More /\bout You Please provide some more information about yourset! to help with your application Race and Ethnicity (OpronaO P!ease se!ect opt10ns from below that best desabe you. Providiog thiS nformat:Dn won~ mpact your eigbity for heath coverage, your heath plan options, or your costs n any way. If H:span;Q'latno ethnd;y che<k a" that appfi Mexican Mexican American Olicano/a Whte Black or African American American Indian or Alaska Native Asian Indian Chnese ~flO Japanese Korean ~ .. : : __ ; :_: ~-.: : .. .: Ale you an Amencan Ind.an or an Atiskan Nat"e? • Additional Information Puerto Rican Cuban Vetnamese Other Asian Native Hawaian GuamanJan or Chamorro Samoan Other Padfic Islander ··················-'·., ... ::J:: We need Sod~ I Security Numbers (SSNs) for l'nyone who wants oover~e . We use SSHs to verify dtizenship. If someone doesn't hli'R l!n SSN, VIsit soaafsecurity.gov or call 1- 801Hn·l213. TTY users should c.olll 800 32S 0778. Do you r.ave an SSt<? • Ale you a us C~izen? • SatJ& & Exit !!ext 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 32 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

7.2.1 Document Types --Please Select-- Certiflcate of Citizenship DS2019 (Certiftcate of Eligibility for Exchange Visitor (J-1) Status) 1-20 (Certificate of Eligibility for Non immigrant (F-1) Student Status 1-94 (Arrival/Departure Record} 1-327 (Reentry Permit} 1-551 (Permanent Resident Card) 1-571 (Refugee Travel Document) 1-688 (Temporary Resident Card) 1-SBBA (Employment Authorization card) I-688B (Employment Authorization Document} 1-766 (Employment Authorization Card) Immigrant Visa (Temporary Resident card) Naturalization Certificate Temporary 1-551 Stamp Unexpired Foreign Passport VVT/WB Admission Stamp in Unexpired Foreign Passport Other 7.3 Primary Applicant- Not f'\pplying for Coverage Supplement 1 to Attachment 3.1 G More About You Values {If applicable) If the applicant did not answer 'YES' to 'Do you want to find out if you ~r ~et help eaying for your own healt~ ipsurance and health benefits?' on SOGinformation About You then the following page . display~ .. > ... >J . <Y ··•·· Please provide some more information about yourself to help with your application Cluster: Additional Information Because you aren't applying for health insurance, you may provide a Social Security number (SSN) if you have one. It's optional. We'll use this SSN to check your income. This can speed up the decision about whether household members get help paying for assistance. SSN 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland - Page 33 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

7.4 Existing Coverage .llflliBBIIIIRIIilniM!l iii Cluster: Existing Coverage Found Member Name Source of Coverage Start Date End Date If you feel this information is incorrect you may continue this application and then you will need to contact your Local Health Department. If you are.an existing Medicaid or MCHP client and would like to submit your renewal please exit the application and click the link that allows you to link to your existing case on your account home page. Supplement 1 to Attachment 3.1G f.' Y<'Y :f"('l tl-.0,. ~~~, •••• ,~:oo ;s i:o:< r.tf~t ~ ::1.1~· .:<o:-~l it"M! thh ~~.:at(o~ ..1::-.t '?'h.·)"~:("'~~~ ~.;1 r~ .;c.·.sa<l 1·.;.;;• ~<-"'-. : it,...,;Jf?.. r.<'~'t•W.·ll, t• '/'N 11:;• ... ~ ... -..isd:o:t; t.~6dia~ ,_~ 1\!(tir' -- ~~~- •:o:~ w~~:d t~ t;;;o -~~a y~ no-,.,.,.JI: Wt.U 't f-A~; fM A~;o~:<: All~ +M 'I:~I(.S.. f~f> :i;o;~ ;,:-.:.n .~to,..,, N:.c ~<:> l:n=...l.t -,:-;:.;1 stals':.>~!i; <41+ ~,.. 'f"J~' • ~.r~ .... nt !"~~~ P•S• · 7.5 Supporting Documents Naturalization Certificate has been selected to be the supporting document for the status of being a U.S National. Please provide the below information as available in the document. Please enter the Name and Date of Birth if different from what is already entered in the nt Information. (This supporting document about 'Naturalization Certificate' appears, when tf1e user selects any option for the field 'Supporting Document ~ which is under the a US 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 34 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

!··94 (ArrivaVDeparture Record) has been selected to be the supporting document for the status of being a Lawfui Alien. Please provide the beiow information as available in the document. Please enter the Name and Date of Birth if different from what is already enten?.d Certificate of- Citizenship has been selected to be the supporting document for the status of being a Lawful Alien. Please provide the below information as available in the document. Please enter the Name and Date of Birth if different from what is already entered DS2019 (Certificate of Eligibility for Exchange Visitor (J- 1) Status) has been selected to be the supporting document for the status of being a l.awfui Alien. Please provide the below information as available in the document. Please enter the Name and Date of Birth if diff<:)rent from what is already entered in the Applicant Supplement 1 to Attachment 3.1 G (This banner text and the related fields appear, when the user selects the option 1-94 for the field 'Supporting documents~ which is under the primary in the United States?'} {This banner text and the related fields appear, when the user selects the option 'Certificate of Citizenship' for the field 'Supporting documents~ which is under the primary filed 'Are you lawfully present in the United (This banner text and the related fields appear, when the user selects the option '052019 Certificate' for the field 'Supporting documents~ which is under the primary filed 'Are you lawfully present in the United States?' 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 35 of 66 TN No: MD-13-0021 -MM2 Maryland Approval Date: 0211212014 Effective Date: 10/0112013

1·-20 {Certificate of Eligibility for Non immigrant (F·l) Student Status has been selected to be the supporting document for the status of" being a Lawfui Alien. Please provide the below information as available in the document. Please enter the Name and Date of Birth if diff-erent from what is already entered in the Applicant Information. 1-327 (Reentry Permit) has been selected to be the supporting document for the status of being a Lawful Alien. Please provide the below information as available in the document. Please enter the Name and Date of Birth if different from what is already entered 1-551 (Permanent Resident Card) has been selected to be the supporting document for the status of being a Lawful Alien. Piease provide th~; below information as available in the document. Please enter the Name and Date of Birth if different from what is already entered in the Applicant Information. Supplement 1 to Attachment 3.1 G (This bonner text and the related fields appear, when the user selects the option '1-20 Certificate of Eligibility for Fl 'for the field 'Supporting documents: which is under the primary filed 'Are you lawfully in the United States?' (This banner text and the related fields appear, when the user selects the option '1-327 {Reentry Permit}' for the field 'Supporting documents', which is under the primary filed 'Are you lawfully present in the United States?') (This banner text ond the related fields appear, when the user selects the option 'I 551(Permonent Resident Card} for the field 'Supporting documents~ which is under the primary filed 'Are you/awfully present· in the United 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 36 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 0211212014 Effective Date: 10/01/2013

1-571 {Refugee Travei Document} has been selected to be the supporting document for the status of being a Lawful Alien. Piease provide ti1e beiow information as available in the document. Please enter the Name and Date of Birth if different from what is a!ready entered 1-688 {Temporary Resident Card) has been selected to be the supporting document for the status of being a Lawfui Alien. Piease provide the be! ow information as available in the document. Please enter the Narne and Date of Birth if different from what is aiready entered I-688A (Employment Authorization Card) has been selected to be the supporting document for the status of being a lawful Alien. Plf!ase provide the below information as available in the document. Please enter the Narne and Date of Birth if" different from v.;hat is a! ready entered in the Applicant Information. Supplement 1 to Attachment 3.1 G (This banner text and the related fields appear, when the user selects the option '1-571 (Refugee Travel Document}' for the field 'Supporting documents~ which is under the primary filed 'Are you lawfully in the United States?' (This banner text and the related fields appear, when the user selects the option '1-688 (Temporary Resident Card)' for the field 'Supporting documents~ which is under the primary filed 'Are you lawfully present in the United States (This banner text and the related fields appear, when the u.5er selects the option 'I-688A (Employment Authorization Card}' for the field 'Supporting documents~ which is under the primary filed 'Are you in the United States 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 37 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

I-688B (Employment Authorization Document) has been selected to be the supporting document for the status of being a Lawful Alien. Please provide the beiow information as available in the document. Please enter the Name and Date of Birth if different from what is already entered in the Appiicant Information. Hi88B (Employment Authorization Document) has been selected to be the supporting document for the status of being a Lawful Alien. Please provide the below information as available in the document. Please enter the Name and Date of Birth if differ('!l1t from what is aiready entered in the Applicant Information. 1-766 (Employment Authorization Card) has been selected to be the supporting document for the status of being c lawful Alien. Please provide the below information as available in the document. Please enter the Name and Date of Birth if different from what is Immigrant Visa (Temporary Resident Card) has been selected to be the supporting document for the status of being a lawful Alien. Please provide the below information as available in the document. Please enter the Name and Date of Birth if diHerent from what is already entered in the Applicant Information. Supplement 1 to Attachment 3.1 G (This banner text and t'he related fields appear~ when the user selects the option '1-6888 {Employment Authorization Document}' for the field 'Supporting documents~ which is under the primary filed 'Are you in the United States?') (This banner text and the related fields appear, when the user .selects the option '1-766 {Employment Authorization Card}' for tile field 'Supporting documents: which is under the primary filed 'Are you in the United States (This banner text and the related fields appear, when the user .selects the option 'Immigrant Visa (Temporary Resident Card' for the field 'Supporting documents', which is under the primary filed 'Are you present in the United 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 38 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

Naturalization Certificate has been selected to be the supporting document for the status of being a Lawful Alien. Please provide the below information as available in the document. Please enter the Name and Date of Birth if" different frorn what is aiready entered in the Applicant Information. Temporary 1-551 Stamp has been selected to be the supporting document for the status of being a Lawful Alien. Please provide the below information as available in the document. Please enter the Name and Date of Birth if different from what is already entered Unexpired Foreign Passport has been selected to be the supporting document for the status of being a Lawful Alien. Please provide the below information as available in the document. Please enter the Name and Date of Birth if different from what is already entered in the Applicant Information. Supplement 1 to Attachment 3.1G (This banner text and the related fields appear, when the user selects the option 'Naturalization Number' for the field 'Supporting documents~ which is under the primary filed 'Are you lawfully present in the United States? (This banner text and the related fields appear., when the user selects the option 'Temporary f-551 Stamp' for the field 'Supporting documents~ which is under the primary filed 'Are you lawfully present in the United (This banner text and the related fields appear, when the user selects the option 'Unexpired Foreign Passport' for the field 'Supporting documents', which is under the primary filed 'Are you lawfully present in the United States?') 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 39 of 66 TN No: MD-13-0021 -MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

\NT/WB Admission Stamp in Unexpired Foreign Passport has been selected to be the supporting document for the status of being a Lawfui Alien. Please provide the below information as available in the document. Please enter the Name and Date of Birth if different frorn what is already entered in the Applicant Information. Other has been selected to be the supporting document for the status of being a lawfui Alien. Please provide the below information as available in the document. Please enter the Name and Date of Birth if different frorn what is already entered in the Applicant Information. Supplement 1 to Attachment 3.1 G (This banner text and the related fields appear, when the user selects the option 'WT/WB Admission Stamp' 'Supporting documents~ which is under the primary in the United States? (This banner text and the related fields appear, when the user selects the option 'Other' for the field 'Supporting documents', which is under the primary in the United States?') 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 40 of66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

tion Number Passport Number Visa Number Card x• Number Citizenshi x• p Certificati on Number 1-94 x• Number SEVIS ID Document X X X X Expiration Date First X X X X X X Name Middle X X X X X X Name Last Name X X X X X X Date of X X X X X X Birth 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland X X X X X Supplement 1 to Attachment 3.1 G x• X X X X X X x• X x• X X X X X X X X X X X Page 41 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013 x• X x• X X X X X

Supplement 1 to Attachment 3.1 G <'} Household Member Extra Details More Information about Judy t~· ~-' ~'1ar11r. Judy Race and Elhnicity (Optvnal) Please select aprons from below mat best descrne Judy. This ilformation s captured for statlStcal purposes onty. The response ~.i not inpact the ildr.-<Juals eigbit,- for assistance. Mexican Mexican American OliCilna/a Whte Black or African AmeriCan Amencan Indian ;,r Alaska Native Asian Indian Olilese Ffpila Japanese Korean : .. .: ~--= Is Judy an Amencan lnd"n or an Alaskan native? • Additional Information Puerto Rx:an Cuban Vietnamese Other As"n Native Hawaian Guamanian or Chamorro Samoan Other Pacific Islander : ... : c:.~ We need Social Seanity Numbers (SSNs) for ~nyone who wl!nts coveroge. We use SSNs to verify dt!Zenship.lf someone doesn't hove on SSN, vtsit sod~lsecunt'(.gov or coli 1-BD0-772·1213. TTY users stlou!d colll 800 325 0778. Does Judy have an SSN? • Is .Judy a US Citizen? •· Is JUdy rurrentty pregn~nt or gave birth In the ~st 3 months? l!: Save- & Exit 7.6 Married Couple FHing Jointly l ,!!lllliiiii,PIIIIIl ;;, ri ••·········'llii!L:·••••····· Banner Please indicate the filing status of the below couple(s). --Pie3se Select- ·-Pie3se Select- 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland tlext Page 42 of 66 Approval Date: 0211212014 Effective Date: 10/01/2013

You have indicated that the following people in your household are married and expected to file taxes - to ensure you get the right help in paying for your health insurance, we need to know whether they intend to file jointly or separately. Does <primary> plan to file a joint federal tax return with <name> next year? Will <tax filer> be claimed as a dependent on someone else's federal income tax return? ~.~ ~ :: .. : ~ ·,,•' .. Please indicate the ning status of the below coupleis) Jerry Mi1:t-: Supplement 1 to Attachment 3.1 G S \'cu r.;·.:e l!l\i:("a!e~ .t:--,~;. t:--:e t~::,:.win~ PO:•Jple ir. ~'~:...: ~ h:1~sei~CI·j ;r; l":"':;::1;.:; ;;n,~ !="i.p;~ ''' 1i:e t3.~e$ - t-:• ;r:s,;r; r ·:t\1 g;l !:~e tight t;i:l::> :tl ~;;~~ r.g 1.J~ ;-em· hfa:;t. ::~$l:f3:~~t-. '"'e n;;:o.:flu ~nc;~· wrt~?!!":~r the;- lnte:-~c. IIJ tile jo:.!r::ir ·:-r !e~ar.::te~~- Does Jerry plan to file a JOint rederaltax return with Marty ne>-1 year? -s· Will Jerry be dalmed as a dependent on someone else's federal Income tax return? .,.. save & Exlt 7.7 Oependents Please indicate who claims [name) as a dependent For anyone in your household who isn't expected to file taxes themselves, we need to know whether they are expected to be included as either a spouse or dependent on the tax return of else in the household. Is anyone outside this household No expected to enter [name) as a spouse or Yes rlPinPr'rl~•nt on their tax return? 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland No Page 43 of 66 Approval Date: 0211212014 Effective Date: 10/0112013

Who expects to claim [name] as a spouse or dependent on their tax return? ~ Add;tiona! !nbrmat;or: about the next persGn GetUng Slarteo ~ Please ln::tieate who cla11ns t..tary as a deP'(:n::1enl Applkant Details Supplement 1 to Attachment 3.1 G Mary AddllonaJ Househok1 Information tj "Cr ,);:><··'e ·:: ·:·<·:..'f :..:::,!-~:l~-:t-:- .-.:\·:· ~-::·1 N:;;ect·1 I·} t-:~ ::>.~ (·!:' 11:~. --.·-sc.-1-.e~ .. ,~. r::;•}::: ::; o:r,.:;y~ .-.~.;-:a-:- : t:-.e:. :-:e O:>t:~·::<-~ :~ ~-e -::c::.~-1ecta:- t·l::c·J 3: ~ t ·)~::··} H :;:-}l!:··l:c-n: ¥11:-:t :-:·> :2=:-J:: .. :;:t .'!'•':''>:"· ?:-:1 1::l::c· :':{·:!~·:;::c-1:: ts an•;one tn this househOld expected to enter Mar:( as a spouse Cof dependent :>n their tax return? t Adellttonat tnccme Information Summary Venflcabon Sunwnary ,. 'A'ho expec.ts to claim Ma.rv as a spouse rx dependent on theu lax retum? 8 Section VIII - More about this household Please answer these additional questions about the household Additional information on the household, such as whether someone is disabled or blind, will help us work out whether you may be entitled to help on grounds other than your income. Is anyone in the household blind? Is anyone in the household disabled? No Yes No Yes 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Page 44 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Does anyone in the household have a physical, mental, or No emotional health condition that causes limitations in Yes activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home? ~ Additional Information for all Applicants Please answer these additional queslions aooul the household. Is anyone in the household bUnd? • Is anyone in tt.e household disabled? ~ Does Mlyone in the household hC!\"E a phystcal, mental, or emottonal health condibon that causes hmitlltions 1n adlvitJes (hke bothing. dressing. dl!oly chores, etc:.) or live In a mediatl faality or nursing home? • save& Ex~ 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G . . . ·•· .. ~ ~ :·: Back Page 45 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G 9 Section IX- Expedited Income tO Section X- Current/monthly income 10.1 Flow Chart INCOME INFORMATION For each member of household who has income SUMMARY 10.2 ln<.:ome Information ~ !ncorne Information Please select !he 1rldiVJduals De low who have 1nwrne ,. ~ ~:= 'i ' ~a~ t Martm ..:ud• 3f:fl"f Jenn : !~r ~ The page allows you to indicate the members 10 the household who recerve income. 1f you or anyone In the household has any sort of income ~ase ten us about 1t. Does Martm have any income?,.. OefaabtoHO Yes Save& E.Jdt 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021 -MM2 Maryland .... ;_? ............................................ ,, Back Page 46 of66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

10.3 Enter Income Details From the information you have given us <name> has income, please enter <name's> income details below This page is designed to capture income for an individual in the household. If an individual receives income from more than one source, be sure to select 'Yes' for the last question and you will be able to enter additional income records. Please be sure to enter your income before taxes are taken out. Income Amount What portion of this amount is tax exempt? Numeric Annually Bi-Weekly Monthly Quarterly No Yes 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G Page 47 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G ft~ Enter Income Details From the lnformabon you have given us Martin has Income. please enter Martin's Income details below ~: ~- .::: 1; f 1; t · Martin .hE!y 6<HY .. :er::1ife: 6 This page is designed to capb.Jre mcorM for ~n Individual in the household. If an individual rec:etves income from more than one source, be sure to select 'Yes' for the last question and you •nill be able to enter add1tion!:!l1ncome records. Please be sure to enter your Income before taxes are taken out Income Type • wages and Salaries Amount ·.:.= Vthat Is the name o! your EmpiO'fer? Frequency ., --Please Seier!- Start Date • ················································' End Date ··············································' Does Mar1in have any more income? --Please Sele1:t- S!M!&Exlt -Please Select- vVages and Salaries Alimony and rvlaintenance American Indian Alaskan Native Income Dividends Foreign Income Interest Net Self Employment Income Pension/Retirement Benefits Prizes and Awards Farming or fishing Income Rental or royalty income Capital gains Scholarship Payments Social Security Income Lump sum Amount Unemployment Insurance Other :); .... = .. ?.' )· ::{ 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland ·.·: ~-;:: Back tlext Page 48 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

10.4 Income Deductions Certain allowable expenses such as alimony payments can be deducted from your income to make the cost of health insurance a little lower. Please indicate if you incur any of the following: Supplement 1 to Attachment 3.1 G Does <name> pay for certain things that can No be deducted on an income tax return, telling Yes us about them could make the cost of health insurance a little lower. Amount Does <name> have any more Deductible income? Alimony paid Certain business expenses of reservists, performing artists, and fee-basis government officials Deductible part of self-employment tax Domestic production activates deduction Educator expenses Health savings account deduction Moving expenses Penalty on early withdrawal of savings Rent or Royalties Self-employed SEP, SIMPL, and qualified plans Self-employed health insurance deduction Numeric No Yes 594 Maryland - HBE CMS Alternate Application For Health Coverage Page 49 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G u; !ncorne Dedudions Please indi<ate whether Ma111n has any allowable deouct1011s. t· Martin U C;;t:;.;l~ z:to;•at;le e:-tt;er,se-s s~:~!i :_;:_. ar, ~· ;,;:m·: l)fl ~ ~~ =_; ir:~ e:-:~s ..:;;n ~e CeCt.:c:..::·:i !~o:Tl ~ ·:~t:: :r:t::::~e It~ =rJ.J>'.O:: !he(·:: :; ~ o! he:Jt;: ins:J~a:-,ce .J :1~e :.::wef PI-:-~=:: mdic:at:;-1! w..-u ::":C"\1: :.1:: ~ ~ ~ ;.t:,:; f<ll!-:·w:nc. Does Martin pay ror certa•n things that can be deducted on an income lax return. telling us about them could make the cos I ol heatth Insurance a linle lower Deductable Income Deduction lype. * - Please Select-· Amount ' Start Dale • End Date. Frequeocy. « -Please Seie<t-· Does Martin have any more Deduct able income? - Please Select-· save & Exit 10.5 American lndian/ Alaskan Native Excludable Income Next ~ - '-. ' '' \ ~' ' '. ~~ Excludable Income Getting Started Please sele<.! as 11ems thal l an oe e,:.ciOOecl lrom .1'"..1/ln's 1ncorne taA ~tu rn AppliCant Details Housef'lOIO rntocmauon Jonn Jotm has indicated lo Mlfe InCome frOO'l.o\mertcan Man!AiasY.an Uat•·1e sources is , ................•.....•....•.........• , --·riei>me '":C<HICn:J: ~O:.JS·::t:t•!C ;:. ~o:rr.ah:.--n any of this ~rom distributions paymenls. awnerShtp tnletesls and real propet ·~· usage nghts? 10.6 American Indian/ Alaskan Native Income Details Please provide some information about the American Indian or Alaskan Native income <name> has indicated to have income from No American Indian/Alaskan Native sources, is Yes any of this from distributions, payments, ownership interest and real property usage rights? Cluster: American Indian or Alaskan Native Income S94 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Page 50 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G What is the income type? What is the amount expected to be received? How often does <name> receive this income? Is there an end date? Does <name> have any more American Indian or Alaskan Native income? Distributions from Alaska Native Corporations and Settlement Trusts Distributions from any property held in trust Distributions results from real property ownership interests Payments from rents, leases, rights of way, royalties, usage rights, or natural resources Payments resulting from items that have religious or culture significance Student financial assistance from the Bureau of Indian Affairs Frequency No Yes ' / - l .. ,, I' r >< ,, , ..- • Gettmg Slarteo Applicant Details HousehOld lntonnat10n J\..do:!·ona: t:c.J:;e:-:~·:: ;nl·:o:·r·Xl:!:CrJ $·~, American Indian-or .Alaskan Natve Detai!s Please pr:Wide SomE: in~orma!ion about the Ame!'IC.an IOOian Of AJaskan Nah\.-e me orne. American lndtan or Alaskan Nattvc Income 'Ntlal rs the tn::ome type? :>~. \"JMt is tne amount e);pecte<llo oe rece"·e<P » HoW often csoes J:>nn re<el'le !t,ts Income? :< 'Nhat is the start :late? :c ts there an end date? Does John ha\'e any mere American lndJan or Alaskan f'Jatl'le ~rKome ? .... S94 Maryland- HBE CMS Alternate Application For Health Coverage Page 51 of 66 TN No: MD-13-0021-MM2 Maryland Approval Date: 0211212014 Effective Date: 10/01/2013

10.7 Summary 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G Page 52 of 66 Approval Date: 02112/2014 Effective Date: 10/01/2013

·.-:-.. .,., . ,,.:.,_:}-.,, .~.,. t:·+5Nf2tMth&i•;! 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G Page 53 of 66 Approval Date: 0211212014 Effective Date: 10/01/2013

10.8 Annual Income Please review the annual income calculation for <name> We have calculated what we expect the annual income for this person to be based on the information you have provided us. This may not match your expectation of what the annual income will be (for example, if this person's income fluctuates during· the year) - if that is the case, please indicate so below. If you told us you had income deductions this is reflected in the amount shown. Based on the information you have provided the expected annual income for <name> is <$amount> Is this what you expect <name's> annual income to No be? Yes tl Annuc:ll !nccrne ~ase review the annual income calculation ~ar Martin .:::- •· <- :=::::::: t rw 'I' Martin Jl,<l~ E.a:-:'1 Based on lhe in!onnation yoo have provided. the expected annualontome for Maron IS 525 000 00 Is this what you expect Martin"s annual Income to be? • No \\'hat do you expect the annual Income 10 be? ! 25.00000 save-&Exit 11 Section XI - Discrepancies Supplement 1 to Attachment 3.1 G t · Jer:n:f-er Next MHC displays this page only for any applicant who has failed the reasonable compatibility test and is not eligible for Medicaid or CHIP. 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Page 54 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

11.1 Income Discrepancies You have indicated that your wages have decreased. Our records indicate that you earn more than you just reported to us. It is possible that our records are out of date. To help us understand if this is the problem, please indicate if you have experience any of the following changes in the past three months (check all that apply): r1 IncoJne D~screpanc ies Supplement 1 to Attachment 3.1 G Our records ndicate that you earn more than you just reported to us. It IS possble that our rernrds are out of date. To hep us understand tf this is the problem, please n<ftcate if you have experenced any of the folowing changes n the past three months (check al that apply}: ' Inrome Discrepancy Lost a job L .. ; On unpaid IECJ\'e (for e~mp te, to care for ll f' .. neV'•' bab)') Other ( pl::~se e-:<pl~ in below:~ Please add any addtional comments here. Saw& Ex~ Date this change occurred 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021 -MM2 Maryland Back Next Page 55 of 66 Approval Date: 02/1212014 Effective Date: 10/01/2013

12 Section XII - APTC progrant questions 12.1 Additional Insurance Assistance Information Please answer these questions about the household Please choose any of the people below who use tobacco Please choose any of the people below who are incarcerated Please choose any of the people below who are either enrolled on or eligible for employer-sponsored coverage. The access to coverage could be either through their own employment or as an individual related to the employee. Are any of these people eligible to receive, or heave they ever gotten a health service from the Indian Health Service, a tribal health program, or urban Indian health program or through a referral from one of these health programs? 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G Page 56 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013 •

Supplement 1 to Attachment 3.1 G ;•~ 1\dd tionai Insurance Assistance lnkmnation Please answer these additional qU€slions about the household. Indicates a required field Please choose any of the people below who use tot>acco. t Marge ···~ Please choose any of the people below who are Incarcerated. {· ,~. t Homer Marge .. · ·~ Please choose any of the people below who are curren~y enrolled on a health program or plan . t Homer Marge Please choose any of the people below who are erther enrolled on or eligible ror employer-sponsored coverage. The access to coverage could be either through their own employment or as an individual related to the employee (:i: fil t Homer Marge Are any of these people eigble to receive, or have thl!y ever gotten a heath service from the lnd~an Heath Service, a trilal heath program, or urban !ndian heath program or through a referral from one of these heath programs? ¢· ~~ Homer S.¥e&Exit 12.2 Health Program/Plan Coverage Information •• IBHIIIIIZiin-Wiltitltllll. b'i@I Additional Information for Employer (If the user selects the option 'YES' for the question 'Is anyone in your household currently enrolled on a Health Program or Plan?', then the following screen appears) Cluster Name: Health Program/Plan coverage Information Please indicate if [name] is currently enrolled on any of these programs/plans 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Back Page 57 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Apj>O<''" oew. Health ProgrnmiPlan CoYe'age Information P!e>J:S.e lftdfe.afe :t Ha:rfl$ currently en~~ on otlW ··.PieMe Set«t .. cf !flo!'S.e pro~tams .-plans "' 12.3 Employer Sponsored Coverage t.!9:."k<~NP21:-". Y~4K.:.w~P3!"e CM11¥."ll'i;,;~J'I ~uu;:t,¥ F1~ fotaryWld Oti-~'s He.lllth Proguwn iillilmE1!iRJi-@.ilmilllft !I!I F <name> is indicated to have income <xxx>in the form of <income type>. Please enter information on the employer-sponsored coverage corresponding to this employment Employer-sponsored health coverage is coverage that pays a portion of the total cost for medically related expenses such as doctor visits, hospital stays, prescription drugs and durable medical equipment. If you are enrolled in employer sponsored coverage please answer 'Yes'. Is <name> enrolled on employer-sponsored coverage through this employment? Is <name> eligible for the employer-sponsored coverage, but is not enrolled? 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G Page 58 of 66 Approval Date: 0211212014 Effective Date: 10/01/2013

Supplement 1 to Attachment 3.1 G tt Employer-Sponsored Coverage Information Marton os indicated to have oncon1e 25.000 00 on the torm of Wages and Salaoes Please enter information on tile employer.sponsored coverage corresponding tolhis employment till Employt:!r·sponsored health coverage is CO\terage that pays a portion of the total co~ for rrn!'dically related expenses suc.h as doctor vtSits, hospitlll stays, prescr1ption drugs and durable medical equipment. lf you are enrolled In employer sponsored cnven~ge please l!:n9ller >v~. Is Martin enrolled on employer-sponsored coverage through this employment? •· Is Martin ellgibl€ !or the employer-sponsored coverage, but is not enrolled? w 12.4 Additional Information of Employer llftlqt~!IQ&iEM IIiim~: I;; •·.·.······.••··•·•••;••••··••• I•· (If the user selects the option 'YES' for the question 'Is eligible for employer sponsored coverage information?', then the following screen appears) Additional Information for Employer Please provide additional information on the employer-sponsored coverage. The information provided on this page will be used to determine if the coverage qualifies as minimum essential coverage, which may influence the eligibility determination Members of household display Please provide additional information on the employer sponsored coverage. The information provided on this page will be used to determine if the coverage qualifies as minimum essential coverage, which may influence the eligibility determination Cluster: Employer Details Employer Name Employer Identification Number Is Employer employed full time? Cluster: Address Apt/Suite Address City State Zip Code Cluster: Coverage Details Lowest Cost Plan Employee Contribution for self only coverage No 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland :J; Back llext Page 59 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

Frequency of Contribution Please select the household member that are eligible for coverage by the plan entered above and not currently covered under any other employment sponsored plan Is [name] eligible for any other employer sponsored coverage through his employment? Supplement 1 to Attachment 3.1 G Pl~a~e p~o .. idf: a•~d~<:nolmt;;r·'l31iCfl .:Hlthe oemtl~~-er-ftol•li':re~ ~<l:fa~t . 'Tt1e ant.:;r·~lJti<:n pr!t.-:l..!srJ ;:;n \ttts ta'JC «l:J :;:: use-~ t-~ lj::~t-r:lule lfiM ev""'efa;;~:: qua!lfi~~ a~ :':l:ni:llU:!l ::s~::a!la! cO'..erav.: .-,t.tttl :~IJ 1 tr.ll:..~nce 11::: eliy::t:rt)· do?lermmalJ::r- EmplOyer De;.ails Cit, ZirCMel( Coverage Dela1ts Un;esl Cc-st Plan '· Clalfe --Pfease Select-- 12.5 Employer Pkm Coverage 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland --Pte:;sE-Stled- Page 60 of 66 Approval Date: 0211212014 Effective Date: 10/01/2013

(If the user selects the option 'YES' for the question 'Is enrolled for employer sponsored coverage information?', then the following screen appears) Please provide additional information on the employer-sponsored coverage. The information provided on this page will be used in the determination eligibility for the health insurance programs. Please provide additional information on the employer-sponsored coverage. The information provided on this page will be used in the determination eligibility for the health insurance programs. l:i> ···.•-·,·,>·~ · ·.·:· .... v:·l-~ ·.··.·:·:·.···.•.•·.·· ·.• ~-' , .,_.-.;.,.;.· .•.·.-·-.~<·> 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G Page 61 of 66 Approval Date: 0211212014 Effective Date: 10/01/2013

13 Section VIII- Medicaid & CHIP specific questions 13.1 Additional Information for Medicaid/CHIP Applicants Please answer these additional questions about the household Some of these people you are applyfing for appear to be eligible for Medicaid or CHIP. To ensure that these people get the right services, please answer the questions below Does anyone in the household have unpaid medical bills from the last 3 months? Please choose the members who have No unpaid medical bills Yes If anyone select~d 'Yes' to the above questionJ~¥n ~p ~ following questions Are any of these people eligible to receive, or heave they ever gotten a health service from the Indian Health Service, a tribal health program, or urban Indian health program or through a referral from one of these health <name> is indicated to have income <xxx>in the form of <income type>. Please enter information on the ment Same lower No Yes Is <name> enrolled on employer- No sponsored coverage through this Yes employment? 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021 -MM2 Maryland Supplement 1 to Attachment 3.1 G Page 62 of 66 Approval Date: 02/12/2014 Effective Date: 1 0/01/2013

<' Additiona1 Information for Medicaid!CHIP Applicants Please answer these additional questions about the r.ousehold Does anyone in the household have unpaid medica! b1lls from the last 3 months? Please choose the members who have unpaid medical bls: N: the tme the medical bls were nrurred were your househol:l's ncome the same or lower than your household's rurrent ncome? If found nelgble for coverage today would you Ike to be evaluated fur a Retro-ActJve Medicaid determi1ation? Supplement 1 to Attachment 3.1 G Yes t Jennner ~ -.. : Same Are any of these people elgble to receive, or have they ever gotten a heath service from the Indian Heath ServiCe, a trbal heath program, or urban Indian heath program or through a referral from one of these heath programs? ·A Joronny C.".! Martin is Indicated to roave income 25.000 00 In tr.e form o! 'Nages and Salaries Please enter in!om1ation on troe employer-sponsored coverage corresponding to this employmem Is Martin enrolled on employer -sponsored c·overage through this employment? • Save& Exit . 13.2 Unpaid Medical Bills Details From the information you have given us <name> has unpaid medical bills. Please enter <name's> unpaid medical bills details below. This page is designed to capture details about unpaid medical bills for an individual in the household in the last 3 months. If there is more than one unpaid medical bill be sure to select 'Yes' for the last question and you will be able to enter additional unpaid medical bills details. Does <name> have any more unpaid No medical bills? Yes • No S94 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland : "' :7: Back llext Page 63 of 66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

14 Section XV Review & Sign Submit Application App licants selects 'SUBMIT' Display Submit Application 5123 14.1 SubmitApplication Yes Display Submit Application Confirmation 5124 Please read the following termas and conditions indicate consent and sign. If you disagree with a .statement additional questions may appear or your eligibility for programs may be impacted. A signature is required to complete the application process and submit your application to the I know that if Medicaid pays for a medical expense, any money I get from other health insurance or legal settlements will go to Medicaid in an amount equal to what Medicaid pays for the expense. I know I'll be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell the agency and won't have to cooperate 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021 -MM2 Maryland No Supplement 1 to Attachment 3.1 G Display Submit Ap plication Renewal 5130 .... ... Page 64 of66 Approval Date: 02/12/2014 Effective Date: 10/01/2013

I understand that if I'm eligible for help paying for health insurance, I may also be able to renew the coverage. During the renewal process, the Maryland Health Connection will use income data including information the tax returns of household members. This will determine yearly eligibility for help paying for health insurance of the next 4 years. The Maryland Health Connection will send me a notice and let me make changes. If I don't respond, the Maryland Health Connection will continue my eligibility at the level indicated by the data. I understand this renewal process will occur each year for the next 5 years unless I tell the Maryland Health Connection that I don't want to renew or if I leave the Maryland Health <;:onnection. I also understand that I can change my answer later. If I don't check the box, I can select less than 5 years. If I think the Health Insurance Maryland Health Connection or Medicaid/Children's Health Insurance Program (CHIP) has made a mistake, I can appeal its decision. To appeal means to tell someone at the Health Insurance Maryland Health Connection or Medicaid/CHIP that I think the action is wrong, and ask for a fair review of the action. I know that I can find out how to appeal by contacting the Maryland Health Connection at <x-xxx-xxx-xxxx>. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me. I know that under federal law, discrimination isn't permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file I'm signing this application under penalty of perjury. This means I've provided true answers to all the questions on this form to the best of my knowledge. I know if I'm not truthful, there may be a penalty. 594 Maryland - HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021-MM2 Maryland Supplement 1 to Attachment 3.1 G Page 65 of 66 Approval Date: 0211212014 Effective Date: 10/01/2013

14.2 Submit Application Renewal Submit Application * I give permission for my· eligibility- for help paying for health insurance to be renewe{j for a period of: b,2years (':) 3 years (.:') 4 years (':':, Dollt renew my eligibility for help paying for health insurance Cancel 14.3 Submit Application Confirmation ~we • m. Submit Application Your application has been successfully submitted. Please lNrite down your Reference Numberfor future use. Reference Number: 25G Follow-up If any of the information y ou submitted on this applic ation requires follow-up {for example if we can't automatically verify some information} an agency representative will c ontact y ou using y our preferred contact method. If you would like to talk with an agency representative please CAll your JoGll office at <XXX-XXXX> Close 594 Maryland- HBE CMS Alternate Application For Health Coverage TN No: MD-13-0021 -MM2 Maryland Supplement 1 to Attachment 3.1 G Page 66 of 66 Approval Date: 0211212014 Effective Date: 10/01/2013

Table of Contents State/Territory Name: Maryland State Plan Amendment (SPA) #:MD-13-0022-MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form - CMS 179 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mali West Suite 216, The Public Ledger Building Philadelphia, Pe1msylvania 19106---.':3499 CMS C[NTERS FOR MEDICARE & MEDICAID SERVICES Region HI/Division of Medicaid and Children's Health Operations SWIFT#: 121720134031 JAN 1 0 2014 Charles J. Milligan Jr. Deputy Secretary Health Care Financing Maryland Department of Health and Mental Hygiene 201 West Preston Street, Room 525 Baltimore, MD 21201 Dear Mr. Milligan: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 13-0022- MMJ. This SPA incorporates MAGI based income methodology into the State of Maryland's State Plan in accordance wilh the Affordable Care Act. The effective date for this SPA is January I, 2014. Enclosed is a copy of the following approved State Plan pages: • SlO, pages 1-2 In addition, enclosed for your records is the CMS Summary Page (CMS- .179 form) and the Superseding Pages of State Plan Material. The Superseding Pages document should also be incorporated into a separate seclion in the front of the State Plan. Notwithstanding any other provisions of the Mm·yland Medicaid State Plan, the finm1cial eligibility methodologies described in State Plan Amendment MD-13-0022-MM3 will apply to all MAGI-based eligibility groups covered under Maryland's Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups. If you have questions about this SPA, please contact Lieutenant Commander Andrea Cunninghan1 ofmy staff at (215) 861-4325. Enclosures (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /S/

MD.0592.ROO.OO- Jan 01 , 2014 Page I of2 Medicaid State Plan Eligibility: Summary Page {CMS 179) State/Territory name: Maryland Transmittal Number: Please enter the Tmnsmittal Number (TN) in the format ST- J'Y-0000 where ST= the state abbreviation, Yr =tile last two digits of tile ~b'!'!~~!(}''-l..~f!r, rmd 0000 = 11 four digit number with /eatling zeros. 711e dashes must also he entered. MD-13-0022 Propos~~ ~[f~~_tiv(!}?ate 01/01/2014 (mm/dd/yyyy) Fede~:~~ ~t.a_~UJ£[~cglllation Citation 1902(e)(l4); 42 CFR 435.603 · Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment $0.00 $0.00 Amount Attesting that the state will apply MAGI-based methodologies consistent with 42 CFR 435.603 Governor's Office Review Governor's office reported no comment Comments of Governor's oft1cc received Describe: No reply received within 45 days of submittal '~' Other, as specified Describe: Authority delegated to Deputy Secretary for Health Care Financing, Charles Milligan. Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Moll)' Mana Jan 7, 2014 Dec 13, 2013 (b) (1) (A), (b)

SUPERSEDING J> AGI£S OF' STATE PLAN MATERIAL TRANSMITT A.L NUMBER: MD-13-0022-MM3 PAGE NUMBER OF THE PLAN SECT JON OR ATTACHMENT: SIO -MAGI Income Methodology ' ---------------------------------------~ STATE: Maryland --~ PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (ljApplicable): , Notwithstanding any other provisions of the Maryland Medicaid I State Plan. the financial eligibility methodologies described in I State Plan Amendment MD-l3-0022-MM3 will apply to all / MA~ 1-?ased eligibility groups covered_ under Marylan.d's . ! I ~eel teat? S~ate Plan. The MAGI tinanctal methodolo~te~ set torth i tn 42 Cf R § 435.603 apply to everyone except those mdtvtduals : financial eligibility provisions ofthe Medicaid State Plan only j with respect to the MAGI-based eligibility groups. ! j described at 42 CFR § 435.603(j) for whom MAGI-based methods ! do not apply. This State Plan Amendment supersedes the current I -----------------------------· -- I

Medicaid Eligibility OMJ3 Control Numbt:r 0938 - 114~ OMB Expiration date · I0/31i2014 ~AGI-Based Income Methodologies 1902{c)(14) 42 CFR 435.603 OO The s~ale will il~ply Moclifil:d Adjusted Gross Income (MAGIJ-bused methodologies as described hdmv, nnd consistent with 42 CI--R 435.60_,, In the <.:liSe of determining ongoing eligibility for bendidnrics determined eligible for Medicaid on or before Dccembn 31. 2013. MAGI-based income methodologies will not be applh:d until March 3t. _014, or 1 h' next regularly-scheduled renewal of eligibility, whichever is latt:r, if application of such methods results in a determination of ineligibility prior to such date. In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expet.:il:d to deliver. In determining family size for the el.igibility ch.:tt:rrnination or the other individuals in a household that includes a prel!.nanl woman: ('The pregnant woman is counted just as herseiL ('The pregnant woman is counted as herself, plus one. l- The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is cktermined consistent with the following provisions: When determining eligibility for new appli<.:ants. financial eligibility is hast.:d on current monthly income and family size. When determining eligibility for current hcnefi<:iurics, finant:ial eligibility is based on: r. Current monthly household income and family size ('Projected annual household income and family size for the rcmain.ing months of the <.:urr~nt calendar year [n determining eurrent monthly or projected annual household income, the state will usc reasonable methods to: ~ Include a prorated portion of a reasonably prcdietable increase in future i1K·ornc and/or family size. ~ Account for a reasonably predictable decrease in future income and/or family !>izc. Exl·cpt as provided at 42 CFR 435.603(d)(2) through (d)(4), hnusehold income is the sum of the MAGI-based income o1 every individual included in the individual's household. In determining eligibility I<H Metlicuid, an amount cquivalt:nt to 5 pen.:entagc points of the FPL for the applicable family size will he deducted from lwuschold income in accordance with 42 CFR 435.(i0:1(d). Household income includes actually avai lublc cash support. exceeding nominal amount~, provided by the person claiming an individual described at §435.603(J)(2)(i) as a tax dependent. ('Yes l- No TN No. MD-13-0022-MM3 APPROVAL DATE: January 10, 2014 EFFECTIVE DATE: January 1, 2014 SlO Pave I nl 1

Medicaid Eligibility [!]The age used for children with respect Ln 42 CFR 435.603(f)(3)(iv) is: (' t\gl! Jl) (.'Age 19, or in the cas\! of full-lime studt.:nts, age 21 rRA Disclosure Statement According to the Paperwork Reduction A<.:t of 1995. no persons arc required to respond to a collection of information unless it displays n valid OMB cnntr0l number. The valid OMB ennlrol number for this in[ormation collection is 09~H-ll41-i. The time required to complt.:te this information collection is estimated to average 40 hours per response, inducling the time tn review instruct inns. search existing data re~ources. gather the data needed, and complete and review ihc information collection. If you have comments concerning the accurm.:y nf the time estimatc(s) or suggestions for improving this form, please writt: tn: CMS, 7500 Security Bnulevard. Attn: PRA Reports Clcaranct.: Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1 HSO. TN No. MD-13-0022·MM3 APPROVAL DATE: January 10, 2014 EFFECTIVE DATE: January 1. 2014 Pa11e 2 of 7.

Table of Contents

State/Territory Name: Maryland State Plan Amendment (SPA) #: 13-0023-MM4 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan

/ /S/

MacPro Reporting System: Summary Page (CMS 179) Page 1 of 2

‘aged in ab GAHAN CRS ved aprlicutien tee 304 Medicaid State Plan Eligibility MD.0523,R00.00 - Oct 01, 2013 Home Logout Finder Save _—Validate Print ~~ Help

Control Panel f

Medicaid State Plan Eligibility: Summary Page (CMS 179)

General Information

File Management ‘State/Territory name: Maryland \ Transmittal Number |

YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros, The dashes must also be entered.

‘Summary (CMS179) MD-13-0023

Tribal Input Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, |

Proposed Effective Date i

10/01/2013 ennraeen

Federal Statute/Regulation Citation

42 CFR 431.10

Federal Budget Impact

Federal Fiscal Year Amount, First Year 2014 $ | Second Year =| 2015 $ 0.00 | Subject of Amendment |

To attest that Marylend’s Medical Assistance program is administered ~- in accordance with the provisions of the state plan, requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. |

Governor's Office Review j 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: i | Responsibility delegated to Assistant Secretary of Department of Health and Mental Hygiene Charles Mill:gan who has signed

off on this SPA.

Signature of State Agency Official

Submitted By: Molly Marra i Last Revision Date: May 14, 2014 | | Submit Date: Nov 18, 2013

https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c0 |/print/PrintSelector.jsp 06/17/2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: STATE:

MD 13-0023 Maryland

PAGE NUMBER OF THE PLAN SECTION OR COMPLETE PAGES PARTIAL PAGES ATTACHMENT: SUPERSEDED: SUPERSEDED:

Al - A3 Section 1.4 (page 9) (State Section 1.1 (pages 2-6) Medical Care Advisory Committee)

Section 1.2 (page 7)

Section 1.3 (page 8)

Attachment 1.1-A (Attorney General certification)

Attachment 1.1-B (ICA Waiver)

Attachment 1.2-A (Organizational chart)

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

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

Attachment 1.2-D

Al-A2 Notwithstanding any other provisions of the Medicaid State Plan, the agencies designated in Al and A2 will determine eligibility for coverage to the extent specified in Al and A2.

TN: MD-13-0023MM4. Aprroval Date JUN 1 8 20 14 Effective Date: October 1, 2013

rE Ss Medicaid Administration

CENCE TOE MEDRCARE 4 MAE DOCAID BEVIN

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

Al

State Plan Administration Designation and Authority

42 CFR 431.10

Designation and Authority

State Name: Maryland

As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of] this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department.

Name of single state agency: Maryland Department of Health and Mental Hygiene

Type of Agency: C Title IV-A Agency @ Health C Human Resources

C Other

Type of Agency

The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.)

The state statutory citation for the legal authority under which the single state agency administers the state plan is:

Maryland Code Annotated Health General Section 15-103

The single state agency supervises the administration of the state plan by local political subdivisions. C Yes @No

The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program has been provided.

An attachment is submitted.

The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies.

The single state agency administers the entire state plan under title XIX (i.e., no other agency or organization administers any portion of it).

C Yes @No

TN: MD-13-0023MM4 Approval Date: JUN 18 20 ]dettective Date: October 1, 2013 Page | of 9

S Medicaid Administration

AA OACABE A AAACN VCH

Waivers of the single state agency requirement have been granted under authority of the Intergovernmental Cooperation Act of

1968.

The waivers are still in effect.

@ Yes (No

Enter the following information for each waiver:

Date waiver granted (MM/DD/YY): | 05/23/14

Remove

The type of responsibility delegated is (check all that apply): LJ Determining eligibility Conducting fair hearings (FD Other

Name of state agency to which responsibility is delegated:

Office of Administrative Hearings

Describe the organizational arrangement authorized, the nature and extent of responsibility for program administration delegated to the above named agency, and the resources and/or services of such agency to be utilized in administration of the plan:

Maryland has established an Office of Administrative Hearings (OAH) to provide impartial hearing examiners to conduct contested case hearings for other state agencies, at the state agencies’ option and delegation. Md. Code, Ann., State Government Article (SG) § 10-205. OAH applies the procedural regulations adopted by the agency when, as for Medicaid fair hearings, it is required to do so by State or Federal law. SG § 10-206.

Maryland’s single state agency, the Department of Health and Mental Hygiene, has delegated final fact-finding,

by DHMH at any time (except after an individual case has been delegated), and therefore DHMH retains the ability to ensure its fair hearings are adhering to Medicaid requirements. DHMH has adopted procedural regulations consistent with federal Medicaid fair hearing requirements. COMAR 10.01.04.

OAH, by delegation, renders the final DHMH agency decision as to both facts and law. DHMH, while it monitors OAH decisions, does not conduct further administrative review.

DHMH has delegated eligibility determinations to both the Title IV-A agency, the Department of Human Resources (DHR), and to the Maryland Health Benefit Exchange (MHBE). For non-MAGI based coverage groups, the Title IV-A agency is responsible for referring eligibility appeals to OAH and appearing to represent the Department at the contested case hearing.

DHMH has delegated eligibility decisions for MAGI-based coverage groups to the Maryland Health Benefits Exchange (MHBE). Because of the sliding-scale nature of MAGI-based eligibility decisions, DHMH and MHBE

and to eliminate the possibility of conflicting fair hearings decisions, the Maryland Health Benefits Exchange (MHBE) will track eligibility fair hearing appeals for MAGI-based eligibility. By regulation, DHMH delegates certain administrative responsibility for fair hearings, for state administrative law purposes, to the same delegees (DHR and MHBE) that are responsible for the underlying determinations. However, DHMH has directly delegated to OAH the conduct of fair hearings for Medicaid modified adjusted gross income eligibility appeals. MHBE has made the equivalent delegation to OAH for APTC and CSR cases. Therefore, an appellant of an insurance affordability program will get one fair hearing before OAH where all insurance affordability program

final conclusions of law, and final orders for all of its Medicaid fair hearings to OAH. The delegation is revocable],

have adopted a combined notice to reduce participant confusion. To ensure a seamless experience for participants |)

issues can be comprehensively addressed. Prior to the fair hearing, DHMH or the delegate agency pursues

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informal resolution of issues raised. In the case of DHR, case managers and supervisors explore potential resolutions or explanations with the appellant, and make any necessary corrections or updates to eligibility case records. In the case of the MHBE, the division of Appeals & Grievances is responsible for performing (or assigning to appropriate case managers or navigators) intermediate review and is authorized to go forward with corrections or updates to case data and the eligibility status determination. Under a new law, eligibility decisions for MAGI-based coverage groups will no longer be under the jurisdiction of the Board of Review.

The methods for coordinating responsibilities among the agencies involved in administration of the plan under the alternate organizational arrangement are as follows:

DHMH retains oversight of the State Plan and the state regulations to implement the plan. DHMH monitors the entire appeals process, including the administration of contested case hearings by the Title 1V-A agency and MHBE, and the quality and accuracy of the final decisions made by OAH.

DHMH?’s Office of Eligibility Services provides policy directives and advice to both the Title IV-A agency and MHBE, under their MOUs with the Department. Moreover, the Department actively monitors performance by those agencies and provides resources, through the memoranda of understanding, to ensure timely resolution of fair hearing appeals. DHMH periodically meets with the Title 1V-A agency and MHBE to review the terms of its memoranda as circumstances change.

Under its memorandum of understanding with DHMH, MHBE will conduct certain administrative monitoring functions related to all MAGI-based eligibility appeals, including from eligibility decisions made by the Title IV- A agency, and guide pre-hearing processes, including overseeing informal resolution efforts and case summary preparation. MHBE will direct OAH in its conduct of fair hearings, including specifying available hearing locations, securing appropriate resources to be available at hearings, and ensuring that all appeals are processed and decided within federal regulatory time limits, although DHMH will continue to ensure that MHBE complies with all federal and state laws, regulations, policies and guidance covering the Medicaid program. MHBE and DHMH will each appear at hearings. MHBE or the Title-[V agency, at DHMH's direction, will conduct informal resolution efforts in Medicaid modified adjusted gross income cases, but MHBE will track and monitor these efforts for all MAGI cases, and will report all information obtain through these efforts to DHMH which retains oversight responsibility.

Under delegations made by DHMH to OAH in a Memorandum of Agreement, DHMH also monitors the quality and accuracy of the final decisions made by OAH. Moreover, under Maryland administrative law, either party may seek judicial review of a final agency decision. DHMH monitors OAH decisions and, if a clear error is found, will either 1) engage in settlement with the appellant or 2) exercise its option to seek judicial review when there is clear error by the hearing examiner.

DHMH will ensure that every applicant and beneficiary is informed, in writing, of the fair hearing process by reviewing and approving notices issued by the Title-IV agency, MHBE, and OAH. These notices contain information about fair hearings, how to contact OAH, and how to obtain additional information about fair hearings from OAH.

DHMH will ensure that the Title IV-A agency, MHBE, and OAH comply with all federal and state laws, regulations, policies and guidance covering the Medicaid program.

Remove

Date waiver granted (MM/DD/YY): ]05/23/14

The type of responsibility delegated is (check all that apply): [J Determining eligibility Conducting fair hearings (JF Other

Name of state agency to which responsibility is delegated: TN: MD-13-0023MM4 i Approval pate: JUN 1 8 20 4 Effective Date: October 1, 2013 ayaa Page 3 of 9

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Department of Health and Mental Hygiene’s Board of Review

Describe the organizational arrangement authorized, the nature and extent of responsibility for program administration delegated to the above named agency, and the resources and/or services of such agency to be utilized) in administration of the plan:

In Maryland, a second level of administrative review of some Department final decisions is performed by the Department of Health and Mental Hygiene’s Board of Review. Any party may appeal the final decision of the Department to the Board of Review. The OAH decision is the final DHMH decision, while the Board’s decision is final for purposes of judicial review under the Maryland Administrative Procedure Act for cases where appellants opt for Board review. Pursuant to new law, this appeal is optional and any party may seek direct judicial review of the OAH final decision instead of first seeking review before the Board of Review. The Board of Review is an independent Board, which is not part of the Department, and consists of members appointed by

| the Governor. The Board of Review has authority to make findings of fact and law, but traditionally limits its review to the record established at OAH.

The methods for coordinating responsibilities among the agencies involved in administration of the plan under the alternate organizational arrangement are as follows:

DHMH retains oversight of the State Plan and the state regulations to implement the plan. DHMH monitors the entire appeals process, including the quality and accuracy of the made by the Board of Review. Moreover, under Maryland administrative law, either party may seek judicial review of a final agency decision. DHMH monitors Board of Review decisions and, if a clear error is found, will either 1) engage in settlement with the appellant or 2) exercise its option to seek judicial review when there is clear error by the Board.

DHMH will ensure that every applicant and beneficiary is informed, in writing, of the fair hearing process by reviewing and approving notices issued by the Board of Review. These notices contain information about fair hearings, how to contact the Board of Review, and how to obtain additional information about fair hearings from | the Board of Review. The Board will conduct fair hearings in accordance with Md. Code Ann., HG sec. 2-201 et | seq. and COMAR 10.01.05.

DHMH will ensure that the Board of Review complies with all federal and state laws, regulations, policies and guidance covering the Medicaid program.

Add

oO The agency that administers or supervises the administration of the plan under Title X of the Act as of January 1, 1965, has been separately designated to administer or supervise the administration of that portion of this plan related to blind individuals.

The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are: The Medicaid agency

Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: The Medicaid agency

sz) Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

(J An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act

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S&S Medicaid Administration

CONTE TOE MEDC 4 DREAD VIC

The Federal agency administering the SSI program Indicate which agency determines eligibility for any groups whose eligibility is not determined by the Federal agency: Medicaid agency Title IV-A agency (J An Exchange

‘The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are:

X] Medicaid agency (J An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act (J An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act

The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies.

C Yes @No

State Plan Administration Organization and Administration

42 CFR 431.10 42 CFR 431.11

Organization and Administration

Provide a description of the organization and functions of the Medicaid agency.

Section 2-101 of the Maryland Code, Health-General Article established the State Department of Health and Mental Hygiene to encompass all major departments, boards and commissions with responsibility for regulating health, mental hygiene and related services. Pursuant to Health-General §15-103, the State Department of Health and Mental Hygiene is the single State agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. The Medicaid agency also established and maintains methods, criteria, and procedures that meet all federal requirements for prevention and control of program fraud and abuse.

The Medicaid agency’s responsibilities, other than the ultimate authority of the DHMH secretary, are carried out under the Deputy Secretary of Health Care Financing, one of 5 parallel administrations. The other 4 administrations in DHMH are

+ Regulatory Programs, which includes various DHMH commissions and the various professional boards that monitor health care practice;

* Behavioral Health & Disabilities, which includes the alcohol and drug abuse administration, the developmental disabilities administration, and the mental hygiene administration;

* Public Health Services, which coordinates the activities of local health departments in the 26 counties and includes the Medical Examiner, Vital Statistics and divisions involved in preventive care and health promotion; and

* Operations, which oversees facilities, systems, equipment and staff, and coordinates procurement and regulatory activities, for the other 4 administrations.

Public Health Services includes the Vital Statistics Administration, which supplies data for Medicaid eligibility. Also, Public Health Services shares responsibility with the 26 counties (including Baltimore City) for the local health departments. Although local health departments generally fall under the supervision of Public Health Services, specific employees of each local health department perform Medicaid and CHIP eligibility determinations under the direct supervision of the Health Care Financing administration, which funds these positions and activities using CHIP grants. The office of the DHMH Secretary oversees the Office of Health Care Quality (which surveys facilities) and provides administrative support for the independent Board of Review.

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ccms “Medicaid Administration

Medicaid activities within Health Care Financing are performed through 5 distinct units under 3 Executive Directors and 2 Directors. The Office of Systems, Operations and Pharmacy operates the Medicaid Management Information System, paying claims, furnishing eligibility information to providers, and producing reports; oversees the pharmacy benefit, including convening Pharmacy and Therapeutics Committee, furnishing point-of-service eligibility data to pharmacists, paying for outpatient and inpatient prescriptions, and operating federal and state Medicaid drug rebate program; and is responsible for working with contractors to develop of a fiscal agent system that is intended to replace the current MMIS. In addition to the Office of Eligibility Services (described below), Medicaid has an Office of Health Services, which is responsible for provider and MCO relations and reimbursement, and for designing services and benefit plans. The MMIS and reporting requirements are managed by the Office of Systems, Operations and Pharmacy, which also includes the staff who oversee the state and federal drug rebate programs, set drug coverage policies, and deal with recommendations from pharmacy advisory committees. The Office of Planning and Finance work closely with the Office of Health Services to develop most significant new program areas.

Within Health Care Financing Administration, the Office of Eligibility Services establishes regulations and provides training and informal written guidance to workers responsible for determining eligibility of Medicaid recipients. The Office of Eligibility Services contains a policy division that is responsible for maintaining and developing regulations and informal guidance, and also contains a training unit responsible for developing materials and presenting eligibility classroom training used for all eligibility case workers in DHMH and delegate agencies. Another unit under Policy oversees the local health departments’ determinations of eligibility for pregnant women, families and children, and provides policy support to an operational DHMH unit that processes eligibility, notices and recipient billing/payment for the MCHP Premium program. The Deputy Director for policy also advises the quality control, monitoring and special projects division that performs agency audits, works with the Inspector General’s office on payment error rate measurement, and performs outreach to recipients regarding particular eligibility criteria from time to time in order to promote consistency. The Operations division includes staff who oversee the contractual relationship between DHMH and its enrollment broker for recipient managed care services, and a call center for issues related to transitions between fee-for-service and managed care services and other recipient problems, and also a group of technical experts who maintain accuracy of MMIS records by performing certain manual tasks to bridge the gap between MMIS and the legacy eligibility system, by reviewing system reports and responding to problems, and who maintain the Medicare Buy-In relationship with CMS for dually eligible recipients. Finally, there is a division of case managers who perform eligibility determinations for applicants to the various 1915(c) and 1115 waiver programs (including Increased Community Services and Family Planning), for children in state psychiatric placements, and for the Employed Individuals with Disabilities program (a Medicaid “buy-in” program. These workers use CARES in combination with waiver program systems. Until 2014, this Eligibility Determinations Division (EDD) also had a unit to perform eligibility determinations (using a separate electronic system) for the “pharmacy plus” 1115 program, Primary Adult Care, for childless adults.

Upload an organizational chart of the Medicaid agency.

An attachment is submitted.

Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies.

Maryland's executive branch is made up of 20 Departments and other independent agencies and boards that each report directly to MD's governor, Lt. Governor, and Secretary of State.

The Department of Health and Mental Hygiene is one of Maryland’s 20 departments and is headed by a Secretary who is the Governor’s cabinet-level appointee. See Maryland Manual On-Line maintained by Maryland State Archive at http:// msa.maryland.gov/msa/mdmanual/09dept/htm1/00list.html.DHMH has several sister agencies that provide various social services in Maryland. The Department of Human Resources, DHR, is the Title-IV agency and Title IV-E agency, as well as administering the offices of Child Welfare and Adult Services, Child Support Enforcement among other federal and state public service activities. The Department of Aging provides services to older adults, and certain programs of the Department of Aging are enrolled as Medicaid providers. The Department of Juvenile Services coordinates enrollment with DHR and the Department of certain youth who are in the custody of the State but in community living arrangements subject to court supervision. The office of Disability Determination within the Department of Education partners with DHR in determining disability under Title XVI rules for Maryland residents. The Maryland Health Benefit Exchange is an independent agency and is responsible for the individual exchange market, the SHOP market, and MAGI-based Medicaid eligibility determinations.

As stated above, Maryland has established an Office of Administrative Hearings (OAH) to provide impartial hearing examiners to

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COANE OE EOC ARE 4 AA OSEAN RERVICTY

conduct contested case hearings for other state agencies, at the state agencies” option and delegation, and the Department of Health and Mental Hygiene has delegated Medicaid fair hearings to this entity. Please see Executive Branch attachment for a more detailed structural look at MD's executive branch.

The duties of the Department of Human Resources and of the Maryland Health Benefit Exchange are set forth in detail below in the discussions of agencies that perform Medicaid eligibility determinations.

Entities that determine eligibility other than the Medicaid Agency (if entities are described under Designation and Authority)

Remove

'Type of entity that determines eligibility:

; Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

C An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act C The Federal agency administering the SSI program

|Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

The Maryland Department of Human Resources (DHR) is the State’s agency for programs under IV-A, IV-E, SNAP, and other public welfare programs. DHR operates local Departments of Social Services (LDSS) through District Offices in each of the State’s twenty-four counties. The staff at these LDSS locations includes employees of DHR’s Family Investment Administration who ||process eligibility for Title XIX and Title XXI using DHR’s automated eligibility system, Clients’ Automated Eligibility and Resource System (CARES). These case managers will continue to process non-MAGI Medicaid coverage groups including long term care and foster care. Beginning with the open enrollment period, they will process MAGI Medicaid applications using the State’s marketplace, Maryland Health Connection (MHC). In addition to the LDSS staff, Maryland currently uses eligibility staff at Local Health Departments (LHD) to process eligibility for what will now be MAGI coverage groups, also using CARES. Beginning with open enrollment for 2014, these case managers process eligibility for periods beginning January 2014 or later using MHC. Both groups of case managers (LDSS and LHD) will use CARES to perform adjustments or determine retroactive eligibility for

periods prior to January 1, 2014. Remove

\Type of entity that determines eligibility:

Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

@ An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act C The Federal agency administering the SSI program

Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

||The Maryland Health Benefit Exchange (MHBE) is a public corporation and independent unit of state government. MHBE ||operates Maryland Health Connection (MHC), an electronic eligibility system and state based exchange that determines eligibility | for all insurance affordability programs, including MAGI Medicaid coverage groups. MHC determines eligibility through its single, streamlined, online application. In this form, individuals can self-attest to their income, family size, and other factors that would go into determining eligibility and be matched with programs and health insurance for which they qualify. MHBE also operates the Connector Program, which consists of six regional Connector Entities. The Connector Entities employ staff who process eligibility through Maryland Health Connection (MHC). MHBE also operates the Consolidated Services Center, a state- ||wide call center that has staff who take applications over the phone and process applications through MHC. Connector Entity and Consolidated Services Center employees use MHC to determine eligibility for MAGI Medicaid coverage groups. Workers in the

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Medicaid Administration

Fulfillment Center are trained to apply Maryland's MAGT rules to correct cases affected by system errors. The Appeals and | Grievances unit of MHBE is responsible for using informal approaches to correct disputed determinations without requiring a

hearing, as well as for sending hearing requests to OAH, tracking cases through administrative and judicial levels, assigning case workers and MHBE representatives to appear at hearing, and securing appropriate locations for holding hearings. | ||The Department of Health and Mental Hygiene provides resources, through the memorandum of understanding, to help oversee and || ||fund MHC, the Connector Program and Consolidated Services Center.

Remove

[Type of entity that determines eligibility:

Cc Single state agency under Title [V-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands

C An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act

@ The Federal agency administering the SSI program

Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility.

||Pursuant to a 1634 agreement, the Social Security Administration determines Medicaid eligibility for Supplemental Income recipients.

| Add

| Remove

C An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act

Entities that conduct fair hearings other than the Medicaid Agency (if are described under Designation and Authority)

|Type of entity that conducts fair hearings: | |

C An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act

|Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. | | | |

Add

Supervision of state plan administration by local political subdivisions (if described under Designation and Authority) Is the supervision of the administration done through a state-wide agency which uses local political subdivisions? C Yes @ No The types of the local subdivisions that administer the state plan under the supervision of the Medicaid agency are: C Counties C Parishes C Other Are all of the local subdivisions indicated above used to administer the state plan?

C Yes CNo

TN: MD-13-0023MM4 Approval bateJ UN 1 8 2014 Effective Date: October 1, 2013 Page 8 of 9

Ccms = Medicaid Administration

State Plan Administration Assurances : AS

42 CFR 431.10 42 CFR 431.12 42 CFR 431.50

Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50.

All requirements of 42 CFR 431.10 are met.

There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12.

The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters.

Assurance for states that have delegated authority to determine eligibility:

There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d).

Assurances for states that have delegated authority to conduct fair hearings:

oO There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d).

oO When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency.

Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings:

The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis.

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

TN: MD-13-0023MM4 Approval pared UN 1] 8 2014 Effective Date: October 1, 2013 Page 9 of 9

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Table of Contents State/Territory Name: Maryland State Plan Amendment (SPA) #: 13-27 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CENTERS FOR MEDICARE & MEDICAID SERVICES Region IWDivision of Medicaid and Children's Health Operations SWIFT #111820134011 NOV 19 2013 Charles J. Milligan Jr. Deputy Secretary Health Care Financing Maryland Department ofHealth and Mental Hygiene 201 West Preston Street, Room 525 Baltimore, MD 21201 Dear Mr. Milligan: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 13-27. This SPA updates the State Plan to specify eligibility of pregnant teens and the treatment of income. The effective date for this amendment is October 1, 2013. The signed CMS-179 form and the approved State Plan pages are enclosed. If you have questions about this SPA, please contact Lieutenant Commander Andrea Cunningham of my staff at (215) 861-4325. Sincerely, Enclosure (b) (1) (A), ( (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /S/

I>E!'I\RTMENT OF lmr\LTII AND HUMAN SERVlCI!S IlEAl. Til CARE I:INANCING ADMINISTRATION I·ORM API'R(J\'FD OMB NO. 093S·O I<JJ TRANSMITTAL AND NOTICE OF APPROVAL OF STATE J>LAN MATERIAL I. TRANSMITTAL NUMBER: \S-dl 2. STATE Maryland fOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 3. PROGRAM IDENTIFICATION: TITLE XIX Of- THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFf-ECTIVE DATE Octooer I . 20 13 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN I8J AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF TI-llS IS AN AMENDMENT (Se?urate 1i·ansmillal {or each ame11dme11t) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: , c.. 48C..F'\2._ L\35 ,d,d.d. Q.Xld.. a. FFY 2013:$ 0 v- Q<::,-\-. b.FFY 2014:$ Q .. 8. PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION A"IT ACHMENT: OR A 11'ACHMENT (If Applicable): Att. 2.2A. pg I h. ( Q'a.-\\) Att. 2.2A, pg 13o... (._ <t;J..-1\l Supplement I to Att 2.2. pg I {.C\.d,-\\) Supplement I to Att2.2. pg I.C.f7a-ll) Supplement 8a to Att 2.6. pg 7lO%-cS) Supplement 8a to Att 2.6. pg 7ld'Z-OS) I 0. SUBJECT OF AMENDMENT: Updating the State Plan to specify eligibility of pregnant teens and treatment or income. II. GOVERNOR'S REViEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMI11'AL I8J OTHER, AS SPECIFIED: Susan J. Tucker, Executive Director Office of Health Services -:-:--,-,~~.,...,..,.~~-=-=----:o..,..,....,--·---.. ·--------.. ·----....,......,:-::--c=-==:-:-:-::::-::---------------··---- 12. SIGNATURE OF s;+f\H:l·A9fN..hY OFFICIAL: 16. RETURN TO: Susan J. Tucker, Executive Director OHS - DHMH 20 l w. Preston St., I Sl noor 14. TITLE: Deputy Secretary, Baltimore. MD 21201 omce of Health Care Financin I 15. DATE SUBMITIED: { \ FORREGIQ~L OFFJ.CE USE ONLY 18. PATE APPROVED: FORM HCFA-179 (07-92) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A) (b) (b) (1) (A), (b) (b) (1) (b) (1) (A) (b) /S/ /S/

Agency* Citation(s) B. ATTACHMENT 2.2-A Page 13a OMB No.: 0938- State: Maryland Groups Covered Optional Groups Other Than the Medically Needy (Continued) - (5) X (6) Individuals receiving active treatment as inpatients in psychiatric facilities or programs (who are under the age of _). Inpatient psychiatric services for individuals under 21 are provided under this plan. Other defined groups (and ages), as specified in Supplement 1 of ATTACHMENT 2.2-A. TN# 13-27 Supersedes TN# 92-11 NOV 19 2013 . Approval Date Effecttve Date OCT 0 1 2013 HCF A 10: 7983E

SUPPLEMENT 1 to ATTACHMENT 2.2-A Page 1 OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Maryland REASONABLE CLASSIFICATIONS OF INDIVIDUALS UNDER THE AGE OF 21 UNDER SECTION 1902(r)(2) OF THE ACT __ Section 1902(f) State X Non-Section 1902(f) State An AFDC-related group authorized under Sections 1902(a)(l O)(A)(ii)(l) and further defined at Section 1902(a)(i) of the Social Security Act and at 42 CFR 435.222 which includes pregnant individuals under the age of 18. TN# 13-27 Supersedes TN # 92-11 Approval Date NOV 19 20 1lffective Date OCT 0 1 2013

SUPPLEMENT Sa to ATTACHMENT 2.6-A Page7 OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Maryland MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902(r)(2) OF THE ACT __ Section 1902(f) State X Non-Section 1902(f) State For the AFDC-related groups authorized under Sections 1902(a)(l O)(A)(i)(III), 1902(a)(10)(A)(ii)(l) and 1902(a)(lO)(C), as further defined at Sections 1905(a)(i), (ii), and (viii) of the Social Security Act, the following more liberal income methodology applies: Disregard the difference between 116% ofthe Federal poverty level (as revised annually in the Federal Register) and the income standard for the household size. For the reasonable classification of pregnant teens under age 18 covered under 42 CFR 435.222 per Supplement 1 to Attachment 2.2-A page 1, the following more liberal income methodology applies: Disregard all income TN# 13-27 Supersedes TN # 08-05 lOGT o 1 2013 Approval Dat~QV 1 9 2.(l \~ffective Date _____ _

Table of Contents State/Territory N arne: Maryland State Plan Amendment (SPA) #: 13-28 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Approved SPA Pages

' DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 150 S. Independence Mall West Suite 216, The Public Ledger Building Philadelphia, Pennsylvania 19106-3499 CMS CENTERS FOR MEDICARE & MED ICAID SERVICES Region III/Division of Medicaid and Children's Health Operations SWIFT#: 111920134016 'DEC 1 '3 2013 Charles J. Milligan Jr. Deputy Secretary Health Care Financing Maryland Department of Health and Mental Hygiene 201 West Preston Street, Room 525 Baltimore, MD 21201 Dear Mr. Milligan: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 13-28. This SPA discontinues coverage for women in the breast and cervical cancer screening program under the State Plan. Women eligible for the breast and cervical cancer screening program will now be served under the State's 1115 waiver. The State is no longer accepting new enrollments under the State Plan and current enrollees will be transferred into grandfathered coverage under the 1115 waiver. The effective date for this amendment is January 1, 2014. The signed CMS-179 form and the approved State Plan pages are enclosed. If you have questions about this SPA, please contact Lieutenant Commander Andrea Cunningham ofmy staff at (215) 861-4325. Sincerely, Enclosure (b) (1) (A), (b) ) ) (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /s/

D~ARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND !·lUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): I. TRANSMITTAL NUMBER: 13-2~ FORM APPIWVI'D OMB NO. U9Jll·OI9:1 2. STATE Maryland 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE DecemaeJ 3 I' 26131H: JAN u. 111Zf) aoJ1 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [gi AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmit/a! [or each amendmew 6. FEDERAL STATUTE/I_{~G~f,).Tlp)'J ~IJA~~ (') 7. FEDERAL BUDGET IMPACT: ~en 1~la.')lJD)(,I\~t )Cf_v .ill-)~~ a. FFY 2013:$ 0 ~ J\c\- b. FFY 2014:$ 0 8. PAGE NUMBER OF THE PLAN SECTION OR A'ITACHMENT: Att 2.2A, pg 23d 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/fApplicable): 1\tt 2.2A. pg 23d 10. SUBJECT OF AMENDMENT: To retlect that Marylaml's !:'!·east ana eervieal eaHeer sereeRing progHuH-is··tttm -€QYereEI ttREier ti:te 1 115 waiver instead of the State PlaR. - S/d: e ~X ~3 II. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMin'AL 12. SIGNATURE o~·~;_flENCY OFFICIAL: 13. TYPED NAM E: Charles J. Milligan, Jr. 14. TITLE: Deputy Secretary, Office ofHealth Care Financin 1s. DArE suBMITTED: \ \( 1 a.; t_3. FORM I-ICF A-179 (07-92) [gi OTHER, AS SPECIFIED: Susan J. Tucker, Executive Director Office of Health Services 16. RETURN TO: Susan J. Tucker, Executive Director OHS - DHMH 20 l W. Preston Sl., l st t1oor Baltimore, MD 2120 I 18:I?AJ'E APPROVED,: (b) (1) (A), (b) (b) (1) (A), (b) (b) (1) (A), (b) /s/ /s/

Agency* Citation(s) 1902(a)(l O)(A) (ii)(XVIII) of the Act TN# 13-28 State: Maryland Groups Covered B. Optional Groups Other Than the Medically Needy (Continued) 23. Women who: Attachment 2.2-A Page 23d a. have been screened for breast or cervical cancer under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program established under title XV of the Public Health Service Act in accordance with the requirements of section 1504 of that Act and need treatment for breast or cervical cancer, including a pre- cancerous condition of the breast or cervix; b. are not otherwise covered under creditable coverage, as defined in section 2701 (c) ofthe Public Health Service Act; c. are not eligible for Medicaid under any mandatory categorically needy eligibility group; and d. have not attained age 65. 24. Women who are determined by a "qualified entity" (as defined in 1920B (b) based on preliminary information, to be a woman described in 1902 (aa) the Act related to certain breast and cervical cancer patients. The presumptive period begins on the day that the determination is made. The period ends on the date that the State makes a determination with respect to the woman's eligibility for Medicaid, or if the woman does not apply for Medicaid (or a Medicaid application was not made on her behalf) by the last day of the month following the month in which the determination of presumptive eligibility was made, the presumptive period ends on that last day. The State covered this group between April 2002 and December 31 5 \ 2013. Approval Date DEc· t·a·2013 Effective Dat{JAN O 1 !O 14 Supersedes TN # 01-04

Table of Contents

State/Territory Name: Maryland State Plan Amendment (SPA) #: 14-03 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

/S/

/S/ /S/

Revision:

Page 79y

State/Territory: __ Maryland

SECTION 4 - GENERAL PROGRAM ADMINISTRATION 4.5 Medicaid Recovery Audit Contractor Program

Citation Section 1902(a)(42)(B)(i) Of the Social Security Act

Section 1902(a)(42)(B)(ii)(I) of the Act

Section 1902 (a)(42)(B)(ii)(I])(aa) of the Act

____ The State has established a program under which it will contract with one or more recovery audit contractors (RACs) for the purpose of identifying underpayments and overpayments of Medicaid claims under the State plan and under any waiver of the State plan.

__X___ The State is seeking an exception to establishing such program for the following reasons:

The state does not currently have a RAC vendor. Maryland posted two RFPs and received no acceptable bids. Based on the procurement process involved, Maryland will have a new contractor in place no later than November 1, 2014.

X__ The State/Medicaid agency has contracts of the type(s) listed in section 1902(a)(42)(B)(ii)(1) of the Act. All contracts meet the requirements of the statute. RACs are consistent with the statute.

Place a check mark to provide assurance of the following:

X__ The State will make payments to the RAC(s) only from amounts recovered.

In accordance with State regulations and State Operating Budget SB 125 (2004), providers must pay the amount overpaid plus a contingency fee which is a percentage of the recovery amount. The overpayment and contingency fee from the provider is collected by the State.

X__ The State will make payments to the RAC(s) ona contingent basis for collecting overpayments.

The following payment methodology shall be used to determine State payments to Medicaid RACs for identification and recovery of overpayments (e.g., the percentage of the contingency fee):

The State attests that the contingency fee rate paid to the Medicaid RAC will not exceed the highest rate paid to Medicare RACs, as published in the Federal Register.

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.

TN # 14-03

Supersedes TN # 12-14 Approval pateJ UL 2 3 20 Vertective Date JAN 0 1 2014

Revision:

Page 79y-1

State/Territory: __ Maryland SECTION 4 - GENERAL PROGRAM ADMINISTRATION

4.5 Medicaid Recovery Audit Contractor Program

Section 1902 (a)(42)(B)(ii)(I1)(bb) of the Act

Section 1902 (a)(42)(B)(ii)(IID) of the Act

Section 1902 (a)(42)(B)(ii)(1V)(aa) of the Act

Section 1902 (a)(42)(B)(ii)(IV)(bb) of the Act

Section 1902 (a)(42)(B)(ii)(1V)(cc) of the Act

X__ 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.

X__ 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):

The contingency fee that will exceed the highest rate paid to Medicare RACs, as published in the Federal Register. Maryland is requesting to exceed the contingency fee rate by 5%.

__X_ The State has an adequate appeal process in place for entities to appeal any adverse determination made by the Medicaid RAC(s).

X__ 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 waiver of the plan.

X__ The State assures that the recovered amounts will be subject to a State’s quarterly expenditure estimates and funding of the State’s share.

X__ 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.

TN # 14-03 Supersedes TN # 12-14

Approval Date PUL 28 20M. ccive Date gl AN 0 1 2014

Table of Contents

State/Territory Name: Maryland State Plan Amendment (SPA) #: 18-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 3) Approved SPA Pages


 

     








 

  

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 801 Market Street Suite 9400 Philadelphia, Pennsylvania 19107-3134 Regional Operations Group SWIFT #071020184122 Dennis Schrader, Secretary Maryland Department of Health 201 West Preston Street Baltimore, Maryland 21201 Dear Mr. Schrader: Enclosed is a copy of the approved State Plan Amendment (SPA), Transmittal Number 18-0005. This SPA moves the Family Planning Program into the Maryland State Plan and expands program eligibility. This amendment would allow individuals of any age, with income at or below 259 percent of the federal poverty level, to qualify for Maryland's Family Planning Program. Maryland predicts a fiscal impact on Medicaid expenditures is at least $338,314 (88 percent Federal Funds, 12 percent General Funds) for Fiscal Year 2019. The effective date for this amendment is July 1, 2018. The CMS 179 form and the Approved State Plan pages are attached. Please also find the attached a companion letter that accompanies the approval of SPA 18-0005 that serves to memorialize our agreement with the state regarding implementation of the eligibility and enrollment processes for the state’s family planning program. If you have questions about this SPA, please contact Ms. Talbatha Myatt of my staff at 215-861- 4259. Sincerely, Francis T. McCullough Deputy Director Eastern Regional Operations Group March 15, 2019 / /s/

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Regional Operations Group 801 Market Street, Suite 9400 Philadelphia, Pennsylvania 19107-3134 Division of Medicaid Field Operations East SWIFT# 071020184122 Dennis Schrader, Director Maryland Department of Health 201 West Preston Street Baltimore, Maryland 21201 Dear Mr. Schrader: Re: SPA MD 18-0005 This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of Maryland State Plan Amendment (SPA) MD-18-0005, which was submitted on July 19, 2018. Maryland submitted this SPA to transition the authority for its family planning program from the state’s section 1115 demonstration, Maryland HealthChoice (demonstration number 11-W-00099/3), to the state plan, consistent with section 1902(a)(10)(A)(ii)(XXI) of the Social Security Act (the Act), implemented at 42 CFR 435.214. During the review of SPA MD-18-0005, CMS learned that Maryland is not operating its family planning program application and eligibility processes consistent with the requirements in applicable statute and regulations. The state has committed to full implementation and compliance with statute and federal regulations by September 1, 2019 by fully integrating application and eligibility determination processes for the family planning and related services eligibility group under 42 CFR 435.214 (Family Planning Eligibility Group), into its integrated eligibility system, Maryland Health Connection. The state must have a coordinated eligibility and enrollment process when an individual applies for Medicaid whether it is through the separate family planning application or the single streamlined application which permits application and eligibility determination for Medicaid on all bases, in accordance with sections 1902(a)(8), 1902(a)(10), and 1943 of the Act and implementing regulations at 42 CFR 435.906, 435.911, 435.214. In addition, the state must use MAGI income methodology to determine eligibility for the Family Planning Eligibility Group, in accordance with section 1902(e)(14) of the Act and implementing regulations at 42 CFR 435.603 and 435.214. March 15, 2019

Page 2- Mr. Schrader The state must provide individuals the opportunity to apply for Medicaid (including for the state’s Family Planning Eligibility Group) in accordance with 42 CFR 435.907. In addition, the state’s Family Planning Program application must ask only the questions necessary to make an eligibility determination consistent with the requirements in 42 CFR 435.214, in accordance with 42 CFR 435.907(e). Beneficiaries whose financial eligibility is determined using MAGI-based income must be renewed once every twelve months, consistent with the renewal processes described in 42 CFR 435.916. CMS sent the state a request for additional information (RAI) on October 5, 2018. Based on the formal RAI response and several subsequent discussions between CMS and the state, Maryland has agreed to implement the following changes to its application, enrollment, and eligibility determination processes prior to and until integration of the Family Planning Eligibility Group into Maryland Health Connection on September 1, 2019: Pre-system integration changes: Timeline Revise the “What Does Medicaid Cover” page of the Maryland Health Connection website to include information on the Family Planning Program. Implemented January 2019 Revise the Maryland Health Connection consumer and worker portals and single, streamlined application dashboards to include information on the Family Planning Program. Implemented January 2019 Revise the eligibility determination page to include information on the Family Planning Program. Implemented January 2019 Include information on the managed care organization (MCO) plan shopping page to note that individuals may be eligible for the Family Planning Program even if they are enrolled in a qualified health plan (QHP). Implemented January 2019 Add information to eligibility notices for individuals determined ineligible for full-benefit Medicaid and eligible for QHPs regarding the availability of the Family Planning Program. Implemented January 2019 Add information to the Family Planning Program application and on the Family Planning Program website to inform consumers about the availability of full Medicaid benefits and include a link to the single, streamlined application. Implemented January 2019 Family application clearly states that coverage is for a 12 month period, that reapplication materials will be sent prior to the end of the 12 month period and that individual must re- apply to continue receiving benefits. Implemented January 2019 Modify and distribute the Family Planning Program application to collect only the information necessary for a MAGI eligibility determination. By March 31, 2019 Implement telephonic access to the single, streamlined application in family planning clinics. By March 31, 2019

Page 3- Mr. Schrader We continue to be available to provide technical assistance. If you have any questions about this letter, please contact Ms. Talbatha Myatt of my staff at 215-861-4259. Sincerely, Francis T. McCullough Deputy Director Eastern Regional Operations Group /s/

0 0 Dennis Schrader Medicaid Director 5th Francis McCullough July 1, 2018 Deputy Director March 14, 2019 March 15, 2019 /s/ /s/

Attachment 3.1A Page 16-A STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND TN#: 18-0005 Approval Date _____________ Effective Date: July 1, 2018 Supersedes TN #: 91-16 4. C. Family planning services and family planning related services for women and men of any age seeking contraceptive services. _____________________________________________________________________________________ Covered Services A. The family planning program covers services and supplies to prevent or delay pregnancy and medical, diagnostic and treatment services provided pursuant to a family planning visit. B. Family planning services and supplies are limited to those services and supplies whose primary purpose is family planning and are provided in a family planning setting. Family planning services and supplies are reimbursable at the 90% matching rate. Family planning services are provided, as listed below: a. Approved methods of contraception; b. Contraceptive management, patient education, and counseling. c. Sexually transmitted infection (STI)/ sexually transmitted disease (STD) testing, pap smears, and pelvic exams in conjunction with the family planning method of choice; d. Drugs, supplies, or devices related to services described above that are prescribed by a health care provider who meets the state’s provider enrollment requirements. C. Family planning related services and supplies are defined as those services provided as part of or as follow up to a family planning visit and are reimbursable at the state’s regular Federal Medical Assistance Percentage (FMAP) rate. Family planning related services are provided, as listed below: a. Colposcopy and procedures done during a colposcopy or repeat pap smear performed as a follow up to an abnormal pap smear which is done as part of a routine/periodic family planning visit. b. Drugs for the treatment of STIs/STDs. A follow up visit for the treatment/drugs and subsequent follow up visits to rescreen for STIs/STDs may be covered. c. Drugs/treatment for vaginal infections/disorders, other lower genital tract and genital skin infections/disorders, and urinary tract infections, where these conditions are diagnosed during a routine/periodic family planning visit. A follow up visit for the treatment/drugs may also be covered. d. Other medical diagnosis, treatment, and preventive services that are routinely provided pursuant to family planning services in a family planning setting. e. Treatment of major complications arising from a family planning procedure such as: i. Treatment of a perforated uterus due to an intrauterine device insertion; ii. Treatment of severe menstrual bleeding caused by a Depo-Provera injection requiring a dilation and curettage; or, iii. Treatment of surgical or anesthesia related complications during a sterilization procedure. Limitations: 1. Preconception/Infertility Services. 2. Drugs for the treatment of HIV/AIDS and hepatitis. 3. Transportation services. 4. Individuals who have had a sterilization procedure or a hysterectomy are not covered for the family planning services/supplies provided through this program. March 15, 2019

Table of Contents

State/Territory Name: Maryland State Plan Amendment (SPA) #: 19-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 801 Market Street, Suite 9400 Philadelphia, Pennsylvania 19107

Division of Medicaid Field Operations East SWIFT #040120194037 June 13, 2019 Dennis Schrader Medicaid Director Maryland Department of Health 201 West Preston Street Baltimore, Maryland 21201 Dear Mr. Schrader: Enclosed is a copy of the approved State Plan 1915(i) Home and Community Based Services Renewal, Transmittal Number 19-0003. The purpose of this renewal is to amend the services and eligibility requirements of the 1915(i) program to expand access to necessary behavioral health services. The effective date for this renewal is October 1, 2019. The CMS 179 form and the Approved State Plan pages are attached. Since the state has elected to target the population who can receive these §1915(i) State Plan HCBS, CMS approves this SPA for a five-year period, in accordance with §1915(i)(7) of the Social Security Act. To renew the §1915(i) State Plan HCBS benefit for an additional five-year period, the state must submit a renewal application to CMS at least 180 days prior to the end of the approval period. CMS’ approval of a renewal request is contingent upon state adherence to federal requirements and the state meeting its objectives with respect to quality improvement and beneficiary outcomes. Per 42 CFR §441.745(a)(i), the state will annually provide CMS with the projected number of individuals to be enrolled in the benefit and the actual number of unduplicated individuals enrolled in the §1915(i) State Plan HCBS in the previous year. Additionally, at least 18 months prior to the end of the five-year approval period, the state must submit evidence of the state’s quality monitoring in accordance with the Quality Improvement Strategy in their approved SPA. The evidence must include data analysis, findings, remediation, and describe any system improvement for each of the §1915(i) requirements.

Page 2 - Mr. Schrader If you have questions about this SPA, please contact Ms. Talbatha Myatt of my staff at 215-861- 4259. Sincerely, Sabrina Tillman-Boyd Acting Deputy Director Enclosures /s/

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State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 1 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 1915(i) State plan Home and Community-Based Services Administration and Operation The state implements the optional 1915(i) State plan Home and Community-Based Services (HCBS) benefit for elderly and disabled individuals as set forth below. 1. Services. (Specify the state’s service title(s) for the HCBS defined under “Services” and listed in Attachment 4.19-B): • Intensive In-Home Services • Community-Based Respite Care • Out-of-Home Respite Care • Family Peer Support • Expressive and Experiential Behavioral Services 2. Concurrent Operation with Other Programs. (Indicate whether this benefit will operate concurrently with another Medicaid authority): Select one: X Not applicable { Applicable Check the applicable authority or authorities:

Services furnished under the provisions of §1915(a)(1)(a) of the Act. The State contracts with a Managed Care Organization(s) (MCOs) and/or prepaid inpatient health plan(s) (PIHP) or prepaid ambulatory health plan(s) (PAHP) under the provisions of §1915(a)(1) of the Act for the delivery of 1915(i) State plan HCBS. Participants may voluntarily elect to receive waiver and other services through such MCOs or prepaid health plans. Contracts with these health plans are on file at the State Medicaid agency. Specify: (a) the MCOs and/or health plans that furnish services under the provisions of §1915(a)(1); (b) the geographic areas served by these plans; (c) the specific 1915(i) State plan HCBS furnished by these plans; (d) how payments are made to the health plans; and (e) whether the 1915(a) contract has been submitted or previously approved.

Waiver(s) authorized under §1915(b) of the Act. Specify the §1915(b) waiver program and indicate whether a §1915(b) waiver application has been submitted or previously approved: Specify the §1915(b) authorities under which this program operates (check each that applies):

§1915(b)(1) (mandated enrollment to managed care)

§1915(b)(3) (employ cost savings to furnish additional services)

§1915(b)(2) (central broker)

§1915(b)(4) (selective

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 2 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 contracting/limit number of providers)

A program operated under §1932(a) of the Act. Specify the nature of the State Plan benefit and indicate whether the State Plan Amendment has been submitted or previously approved:

A program authorized under §1115 of the Act. Specify the program: 3. State Medicaid Agency (SMA) Line of Authority for Operating the State plan HCBS Benefit. (Select one): { The State plan HCBS benefit is operated by the SMA. Specify the SMA division/unit that has line authority for the operation of the program (select one): { The Medical Assistance Unit (name of unit): { Another division/unit within the SMA that is separate from the Medical Assistance Unit (name of division/unit) This includes administrations/divisions under the umbrella agency that have been identified as the Single State Medicaid Agency. X The State plan HCBS benefit is operated by (name of agency) Maryland Department of Health- Behavioral Health Administration This HCBS benefit is operated by the Behavioral Health Administration, a separate agency of the state that is not a division/unit of the Medicaid agency under the Maryland Department of Health organizational structure. In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in the administration and supervision of the State plan HCBS benefit and issues policies, rules and regulations related to the State plan HCBS benefit. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this delegation of authority is available through the Medicaid agency to CMS upon request.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 3 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 4. Distribution of State plan HCBS Operational and Administrative Functions. ; (By checking this box the state assures that): When the Medicaid agency does not directly conduct an administrative function, it supervises the performance of the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. When a function is performed by an agency/entity other than the Medicaid agency, the agency/entity performing that function does not substitute its own judgment for that of the Medicaid agency with respect to the application of policies, rules and regulations. Furthermore, the Medicaid Agency assures that it maintains accountability for the performance of any operational, contractual, or local regional entities. In the following table, specify the entity or entities that have responsibility for conducting each of the operational and administrative functions listed (check each that applies): (Check all agencies and/or entities that perform each function): Function Medicaid Agency Other State Operating Agency Contracted Entity Local Non- State Entity 1 Individual State plan HCBS enrollment ; 2 Eligibility evaluation ; ; ; ; 3 Review of participant service plans ; ; ; 4 Prior authorization of State plan HCBS ; ; 5 Utilization management ; ; ; 6 Qualified provider enrollment ; ; ; 7 Execution of Medicaid provider agreement ; ; 8 Establishment of a consistent rate methodology for each State plan HCBS ; ; 9 Rules, policies, procedures, and information development governing the State plan HCBS benefit ; ; 10 Quality assurance and quality improvement activities ; ; (Specify, as numbered above, the agencies/entities (other than the SMA) that perform each function):

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 4 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 2. The State Medicaid Agency performs eligibility evaluation in partnership with the contracted Administrative Services Organization (ASO), the Behavioral Health Administration (BHA), and the local Core Service Agency (CSA)/ Local Behavioral Health Authority. 3. The BHA, ASO, and CSA/ LBHA perform reviews of participant services plans. 4. BHA ASO 5. The State Medicaid Agency is responsible for utilization management in partnership with the ASO and the BHA. 6. The State Medicaid Agency works in partnership with the ASO and the BHA to perform qualified provider enrollment. 8. The State Medicaid Agency and BHA work in partnership to establish a consistent rate methodology for each State plan HCBS. 9. Rules, policies, procedures,and information development governing the State plan HCBS benefit are developed by the State Medicaid Agency in partnership with the BHA. 10. Quality assurance and quality improvement activities are performed by the State Medicaid Agency and the BHA.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 5 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 (By checking the following boxes the State assures that): 5. ; Conflict of Interest Standards. The state assures the independence of persons performing evaluations, assessments, and plans of care. Written conflict of interest standards ensure, at a minimum, that persons performing these functions are not: x related by blood or marriage to the individual, or any paid caregiver of the individual x financially responsible for the individual x empowered to make financial or health-related decisions on behalf of the individual x providers of State plan HCBS for the individual, or those who have interest in or are employed by a provider of State plan HCBS; except, at the option of the state, when providers are given responsibility to perform assessments and plans of care because such individuals are the only willing and qualified entity in a geographic area, and the state devises conflict of interest protections. (If the state chooses this option, specify the conflict of interest protections the state will implement): 6. ; Fair Hearings and Appeals. The state assures that individuals have opportunities for fair hearings and appeals in accordance with 42 CFR 431 Subpart E. 7. ; No FFP for Room and Board. The state has methodology to prevent claims for Federal financial participation for room and board in State plan HCBS. 8. ; Non-duplication of services. State plan HCBS will not be provided to an individual at the same time as another service that is the same in nature and scope regardless of source, including Federal, state, local, and private entities. For habilitation services, the state includes within the record of each individual an explanation that these services do not include special education and related services defined in the Individuals with Disabilities Education Improvement Act of 2004 that otherwise are available to the individual through a local education agency, or vocational rehabilitation services that otherwise are available to the individual through a program funded under §110 of the Rehabilitation Act of 1973.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 6 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 Number Served 1. Projected Number of Unduplicated Individuals To Be Served Annually. (Specify for year one. Years 2-5 optional): Annual Period From To Projected Number of Participants Year 1 10/1/19 9/30/20 200 Year 2 Year 3 Year 4 Year 5 2. ; Annual Reporting. (By checking this box the state agrees to): annually report the actual number of unduplicated individuals served and the estimated number of individuals for the following year. Financial Eligibility 1. ; Medicaid Eligible. (By checking this box the state assures that): Individuals receiving State plan HCBS are included in an eligibility group that is covered under the State’s Medicaid Plan and have income that does not exceed 150% of the Federal Poverty Line (FPL). (This election does not include the optional categorically needy eligibility group specified at §1902(a)(10)(A)(ii)(XXII) of the Social Security Act. States that want to adopt the §1902(a)(10)(A)(ii)(XXII) eligibility category make the election in Attachment 2.2-A of the state Medicaid plan.) 2. ; New 1915(i) Medicaid Eligibility Group. In addition to providing State plan HCBS to individuals described in item 1 above, the state is also covering the optional categorically needy eligibility group of individuals under 1902(a)(10)(A)(ii)(XXII) who are eligible for HCBS under the needs-based criteria established under 1915(i)(1)(A) and have income that does not exceed 150% of the federal poverty level, or who are eligible for HCBS under a waiver approved for the state under section 1915(c), (d) or (e) or section 1115 to provide such services to individuals whose income does not exceed 300% of the supplemental security income benefit rate (as described in Attachment 2.2A, pages 27 of the State Plan). 3. Medically Needy (Select one): † The State does not provide State plan HCBS to the medically needy. ; The State provides State plan HCBS to the medically needy. (Select one): † The state elects to disregard the requirements section of 1902(a)(10)(C)(i)(III) of the Social Security Act relating to community income and resource rules for the medically needy. When a state makes this election, individuals who qualify as medically needy on the basis of this election receive only 1915(i) services. ; The state does not elect to disregard the requirements at section 1902(a)(10)(C)(i)(III) of the Social Security Act. Evaluation/Reevaluation of Eligibility

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 7 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 1. Responsibility for Performing Evaluations / Reevaluations. Eligibility for the State plan HCBS benefit must be determined through an independent evaluation of each individual). Independent evaluations/reevaluations to determine whether applicants are eligible for the State plan HCBS benefit are performed (Select one): { Directly by the Medicaid agency z By Other (specify State agency or entity under contract with the State Medicaid agency): The Behavioral Health Administration, in conjunction with a contracted administrative services organization, and Core Services Agencies or Local Behavioral Health Authorities, the local mental health authorities responsible for planning, managing, and monitoring public mental health services at the local level. 2. Qualifications of Individuals Performing Evaluation/Reevaluation. The independent evaluation is performed by an agent that is independent and qualified. There are qualifications (that are reasonably related to performing evaluations) for the individual responsible for evaluation/reevaluation of needs- based eligibility for State plan HCBS. (Specify qualifications): The independent evaluation and reevaluation will be completed by the Administrative Services Organization (ASO) on behalf of the Department. Maryland-licensed mental health professionals trained in the use of the applicable standardized tools will perform the evaluations. This may include Psychiatrists, Nurse Psychotherapists (ARNP-PMH), Psychiatric Nurse Practitioners (CRNP-PMH), Licensed Clinical Social Workers, Licensed Clinical Professional Counselors, or a Psychologist 3. Process for Performing Evaluation/Reevaluation. Describe the process for evaluating whether individuals meet the needs-based State plan HCBS eligibility criteria and any instrument(s) used to make this determination. If the reevaluation process differs from the evaluation process, describe the differences: The Administrative Services Organization (ASO), on behalf of the Department will verify eligibility, perform the independent evaluation of needs-based criteria,and pre-authorize all of the medically appropriate mental health services. Final eligibility determination rests with the SMA and the ASO will present its eligibility determination to the Department for final approval and enrollment. A licensed mental health professional will conduct the evaluation, based upon Maryland’s definition of medically necessary treatment which requires services or benefits to be: (1) Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition; (2) Consistent with currently accepted standards of good medical practice; (3) The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and (4) Not primarily for the convenience of the consumer, family, or provider. The evaluator will be familiar with the medical necessity criteria and will use those criteria and the individual’s clinical history to determine eligibility. The evaluator will utilize a psychosocial assessment to generate a score on the ECSII or CASII for the youth, and will compare that to the score generated by the Core Service Agency or Local Behavioral Health Authority based on the same documentation. If necessary, the evaluator will gather additional information by telephone or other means in conjunction with the CSA/LBHA.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 8 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 Specific eligibility criteria, including re-evaluation criteria, are outlined in #5 below. Once the evaluator has determined eligibility for services, a Care Coordination Organization will work with the child and family to develop an individualized Plan of Care (POC) that is consistent with the principles of Care Coordination (i.e. strengths-based, individualized, community-based, etc . The CCO will review the POC at least every 45 days, with a review by the ASO when there is a change to the POC that necessitates a pre-authorization. Re-Evaluation; The ASO will review the most recent POC along with other documentation including financial eligibility at least annually as part of the review for continued eligibility for services. The medical re- evaluation, including a CASII or ECSII , will be completed by the ASO based on: 1. An updated psychosocial assessment from a treating mental health professional supporting the need for continued HCBS benefit services; 2. A CASII or ECSII review by a licensed mental health professional at the Care Coordination Organization (with a CASII score of 3to 6 or ECSII score of 3 to 5) as outlined in Section 1a of the response below to Question 5 “Needs-based HCBS Eligibility Criteria”; 3. A review of HCBS benefits service utilization over the past 6 months. The ASO will make the final re-evaluation determination and inform the SMA of its decision. 4. ; Reevaluation Schedule. (By checking this box the state assures that): Needs-based eligibility reevaluations are conducted at least every twelve months. 5. ; Needs-based HCBS Eligibility Criteria. (By checking this box the state assures that): Needs-based criteria are used to evaluate and reevaluate whether an individual is eligible for State plan HCBS. The criteria take into account the individual’s support needs, and may include other risk factors: (Specify the needs-based criteria):

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 9 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 A child or youth must demonstrate the following minimum requirements to be considered for or to remain in 1915(i) services: 1. Impaired Functioning & Service Intensity: A licensed mental health professional (including Psychiatrists, Nurse Psychotherapists (ARNP-PMH), Psychiatric Nurse Practitioners (CRNP- PMH), Licensed Clinical Social Workers, Licensed Clinical Professional Counselors, or a Psychologist.) must complete or update a comprehensive psychosocial assessment within 30 days of the submission of the application to the ASO. The psychosocial assessment must outline how, due to the behavioral health disorder(s), the child or adolescent exhibits a significant impairment in functioning, representing potential serious harm to self or others, across settings, including the home, school, and/or community. The serious harm does not necessarily have to be of an imminent nature. The psychosocial assessment must support the completion of the Early Childhood Service Intensity Instrument (ECSII) for youth ages 0-5 or the Child and Adolescent Service Intensity Instrument (CASII) for youth ages 6-21. a. Youth must receive a score of: i. 3 (moderate service intensity targeted to multiple and/or complex areas of concern that interfere with child and family functioning), 4 (High Service Intensity) or 5 (Maximal Service Intensity) on the ECSII or ii. 3 (intensive outpatient services), 4 (intensive integrated services without 24 hour psychiatric monitoring),5 (Non-Secure, 24-Hour, Medically Monitored Services) or 6 (Secure, 24- Hours, Medically Managed Services) on the CASII b. For initial evaluation youth with a score of 3-5 on the CASII also must meet one of the following criteria to be eligible based on their impaired functioning and service intensity level: i. Living in the community and • Be 6-21 years old and have 2 or more inpatient psychiatric hospitalizations or ER visits in the past 12 months or • Been in an RTC within the past 90 days

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 10 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 c. For initial evaluation youth who are younger than 6 years old who have a score of a 3-4 on the ECSII either must: i. Be referred directly from an inpatient or day hospital unit, PCP, outpatient psychiatric facility, ECMH Consultation Program in daycare, Head Start, Early Head Start, Judy Hoyer Centers, or home visiting programs; or ii. If living in the community, have one or more psychiatric inpatient or day hospitalizations, ER visits, exhibit severe aggression (i.e. hurting or threatening actions or words directed at infants, young siblings, killing a family pet, etc.), display dangerous behavior (i.e. impulsivity related to suicidal behavior), been suspended or expelled or at risk of expulsion from school or child care setting, display emotional and/or behavioral disturbance prohibiting their care by anyone other than their primary caregiver, at risk of out-of-home placement or placement disruption, have severe temper tantrums that place the child or family members at risk of harm, have trauma exposures and other adverse life events, or at risk of family related risk factors including safety, parent-child relational conflict, and poor health and developmental outcomes in the past 12 months. 2. Other Community Alternatives: The accessibility and/ or intensity of currently available community supports and services are inadequate to meet these needs due to the severity of the impairment without the provision of one or more of the services contained in the HCBS Benefit, as determined by the MDH or its designee. 3. Duplication of Services: The youth may not be enrolled in Adult Residential Program for Adults with Serious Mental Illness licensed under COMAR 1.63.01 and 10.63.04 or a Health Home while enrolled in HCBS benefit. 6. ; Needs-based Institutional and Waiver Criteria. (By checking this box the state assures that): There are needs-based criteria for receipt of institutional services and participation in certain waivers that are more stringent than the criteria above for receipt of State plan HCBS. If the state has revised institutional level of care to reflect more stringent needs-based criteria, individuals receiving institutional services and participating in certain waivers on the date that more stringent criteria become effective are exempt from the new criteria until such time as they no longer require that level of care. (Complete chart below to summarize the needs-based criteria for State Plan HCBS and corresponding more-stringent criteria for each of the following institutions): State plan HCBS needs- based eligibility criteria NF (& NF LOC** waivers) ICF/IID (& ICF/IID LOC waivers) Applicable Hospital* (& Hospital LOC waivers) A child or youth must demonstrate the following minimum requirements to be considered for 1915(i) services: 1) Impaired Functioning Maryland allows reimbursement to nursing homes for eligible persons who require hospital care, but who, because of their mental or Md. Code Reg. 10.22.01.01 contains the following definitions: (2) “Alternative living unit (ALU)” means a residence For inpatient hospital psychiatric emergency detention or involuntary admission, Md.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 11 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 & Service Intensity: A licensed mental health professional (including Psychiatrists, Nurse Psychotherapists (ARNP- PMH), Psychiatric Nurse Practitioners (CRNP- PMH), Licensed Clinical Social Workers, Licensed Clinical Professional Counselors, or a Psychologist.) must complete or update a comprehensive psychosocial assessment within 30 days of the submission of the application to the ASO. The psychosocial assessment must outline how, due to the behavioral health disorder(s), the child or adolescent exhibits a significant impairment in functioning, representing potential serious harm to self or others, across settings, including the home, school, and/or community. The serious harm does not necessarily have to be of an imminent nature. The psychosocial assessment must support the completion of the Early Childhood Service Intensity Instrument (ECSII) for youth ages 0- 5 or the Child and Adolescent Service Intensity Instrument (CASII) for youth ages 6- 21 a. Youth must receive a score of 3, 4 or 5 on the ECSII, or 3, 4, 5 or 6 on the CASII. b. Youth with a score of 4 or less on the CASII also physical condition, require skilled nursing care and related services, rehabilitation services, or, on a regular basis, health- related care and services (above the level of room and board) which can be made available to them only through institutional facilities. Md. Code Reg. 10.09.10. owned, leased, or operated by a licensee that: Provides residential services for individuals who, because of a developmental disability, require specialized living arrangements; (b) Admits not more than 3 individuals; and (c) Provides 10 or more hours of supervision per unit, per week. (25) "Group home" means a residence owned, leased, or operated by a licensee that: (a) Provides residential services for individuals who, because of a developmental disability, require specialized living arrangements; (b) Admits at least four, but not more than eight individuals; and (c) Provides 10 or more hours of supervision per week. (16) “Developmental disability" as a chronic disability of an individual that: (a) Is attributable to a physical or mental impairment, other than the sole diagnosis of mental illness, or to a combination of mental and physical impairments; (b) Is likely to continue indefinitely; Health Gen. §§ 10- 613 through 619 requires that: (1) the individual has a mental disorder; (2) the individual needs inpatient care or treatment; (3) The individual presents a danger to the life or safety of the individual or of others; (4) The individual is unable or unwilling to be admitted voluntarily; and; (5) There is no available, less restrictive form of intervention that is consistent with the welfare and safety of the individual. For voluntary admission to a psychiatric hospital, the requirements of Md. Health Gen. §§ 10–609 and 10-610 for minors must be met, including a formal, written application. A facility may not admit an individual under this section unless: the (1) individual has a mental disorder; (2) The mental disorder is susceptible to care or treatment; (3) The individual understands the nature of the request for admission; (4) The individual is able to give

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 12 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 must meet one of the following criteria to be eligible based on their impaired functioning and service intensity level: i. Living in the community and 1. Be 6-21 years old and have 2 or more inpatient psychiatric hospitalizations or emergency room visits in the past 12 months, or 2. Been in an RTC within the past 90 days. c. Youth who are younger than 6 years old and have a score of a 3 or 4 on the ECSII either must be referred directly from an inpatient hospital or day hospital, PCP, outpatient psychiatric facility, ECMH Consultation Program in daycare, Head Start, Early Head Start, Judy Hoyer Centers, or home visiting programs unit or if living in the community, have two or more psychiatric inpatient hospitalizations in the past 12 months. 2) Other Community Alternatives: The accessibility and/or intensity of currently available community services are inadequate (c) Is manifested in an individual younger than 22 years old; (d) Results in an inability to live independently without external support or continuing and regular assistance; and (e) Reflects the need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are individually planned and coordinated for the individual. continuous assent to retention by the facility; and (5) The individual is able to ask for release

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 13 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 to meet these needs due to the severity of the impairment without the provision of one more of the service contained in the HCBS Benefit Duplication of Services: The youth may not be enrolled in an Adult Residential Program for Adults with Serious Mental Illness licensed under COMAR 10.21.22 or a Health Home while enrolled in the HCBS benefit. *Long Term Care/Chronic Care Hospital **LOC= level of care 7. ; Target Group(s). The state elects to target this 1915(i) State plan HCBS benefit to a specific population based on age, disability, diagnosis, and/or eligibility group. With this election, the state will operate this program for a period of 5 years. At least 90 days prior to the end of this 5 year period, the state may request CMS renewal of this benefit for additional 5-year terms in accordance with 1915(i)(7)(C) and 42 CFR 441.710(e)(2). (Specify target group(s)): This HCBS benefit is targeted to youth and young adults with serious emotional disturbances (SED) or co-occurring mental health and substance use disorders and their families. 1. Age: Youth must be under 18 years of age at the time of enrollment although they may continue in HCBS Benefit up to age 22. 2. Consent: a. Youth under 16 must have consent from the parent or legal guardian to participate; for young adults who are 16 or older and already enrolled, the young adult must consent to participate. Youth over 16 who are in the care and custody of the State, require consent from their legal guardian. b. The consent to participate includes information on the array and availability of services, data collection and information-sharing, and rights and responsibilities under Maryland Medical Assistance. 3. Behavioral Health Disorder: a. Youth must have a behavioral health disorder amenable to active clinical treatment. The evaluation and assignment of a Diagnostic and Statistical Manual (DSM) diagnosis or Diagnostic Criteria 05 (DC 0-5) must result from a face-to-face psychiatric evaluation that was completed or updated within 30 days of submission of the application to the Department or its designee There must be clinical evidence the child or adolescent has a serious emotional disturbance

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 14 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 (SED) or co-occurring diagnosis and continues to meet the service intensity needs and medical necessity criteria for the duration of their enrollment. Because of the clinical requirement that the young person have an SED in order to be covered under the Program, the State will require the young person to be actively involved in ongoing mental health treatment on a regular basis in order to receive 1915(i) services. † Option for Phase-in of Services and Eligibility. If the state elects to target this 1915(i) State plan HCBS benefit, it may limit the enrollment of individuals or the provision of services to enrolled individuals in accordance with 1915(i)(7)(B)(ii) and 42 CFR 441.745(a)(2)(ii) based upon criteria described in a phase-in plan, subject to CMS approval. At a minimum, the phase-in plan must describe: (1) the criteria used to limit enrollment or service delivery; (2) the rationale for phasing-in services and/or eligibility; and (3) timelines and benchmarks to ensure that the benefit is available statewide to all eligible individuals within the initial 5-year approval. (Specify the phase-in plan): (By checking the following box the State assures that): 8. ; Adjustment Authority. The state will notify CMS and the public at least 60 days before exercising the option to modify needs-based eligibility criteria in accord with 1915(i)(1)(D)(ii). Home and Community-Based Settings (By checking the following box the State assures that): 1. ; Home and Community-Based Settings. The State plan HCBS benefit will be furnished to individuals who reside and receive HCBS in their home or in the community, not in an institution. (Explain how residential and non-residential settings in this SPA comply with Federal home and community-based settings requirements at 42 CFR 441.710(a)(1)-(2)and associated CMS guidance. Include a description of the settings where individuals will reside and where individuals will receive HCBS, and how these settingsmeet the Federal home and community-based settings requirements, at the time of submission and in the future): (Note: In the Quality Improvement Strategy (QIS) portion of this SPA, the state will be prompted to include how the state Medicaid agency will monitor to ensure that all settings meet federal home and community-based settings requirements, at the time of this submission and ongoing.)

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 15 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 The State plan HCBS benefit will be furnished to individuals who reside and receive HCBS in their home or in the community, not in an institution. This may include residence in: 1) a home or apartment with parents, family, or legal guardian or living independently, that is not owned, leased or controlled by a provider of any health-related treatment or support services; or 2) a home or apartment that is a licensed family foster care home or a licensed treatment foster care home. These settings are the private homes of foster parents who must meet a number of standard environmental and physical space dimensions of the home which are geared toward the individual needs of the children who live there. Foster home licensing also requires ongoing training for the foster parents, with more rigorous training, support, and consultation for treatment foster parents. These are not group homes with staff providing services. A group home that is not a therapeutic or high intensity group home Person-Centered Planning & Service Delivery (By checking the following boxes the state assures that): 1. ; There is an independent assessment of individuals determined to be eligible for the State plan HCBS benefit. The assessment meets federal requirements at 42 CFR §441.720. 2. ; Based on the independent assessment,there is a person-centered service plan for each individual determined to be eligible for the State plan HCBS benefit. The person-centered service plan is developed using a person-centered service planning process in accordance with 42 CFR §441.725(a), and the written person-centered service plan meets federal requirements at 42 CFR §441.725(b). 3. ; The person-centered service plan is reviewed, and revised upon reassessment of functional need as required under 42 CFR §441.720, at least every 12 months, when the individual’s circumstances or needs change significantly, and at the request of the individual. 4. Responsibility for Face-to-Face Assessment of an Individual’s Support Needs and Capabilities. There are educational/professional qualifications (that are reasonably related to performing assessments) of the individuals who will be responsible for conducting the independent assessment, including specific training in assessment of individuals with need for HCBS. (Specify qualifications): Care Coordinators will be responsible for conducting a face-to-face assessment of an individual’s and family’s support needs and capabilities Care Coordinators are employed by the Care Coordination Organizations (CCOs) and have met all the requirements of being a care coordinator. Qualifications for Care Coordination Organizations (CCOs) are described in COMAR 10.09.90, and all 1915(i) participants are required to receive care coordination services under the same regulations. The State Plan Amendment pages for Care Coordination for Children and Youth include detailed requirements for CCOs. Care Coordinators employed by the CCO must demonstrate the following:

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 16 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 i. Bachelor's degree and has met the Department’s training requirements for care coordinators; or ii. A high school diploma or equivalency and a. Is 21 years or older; and b. Was a participant in, or is a direct caregiver, or was a direct caregiver of an individual who received services from the public and child- and family-serving system; and c. Meets the training and certification requirements for care coordinators as set forth by the Department. d. Is employed by the CCO to provide care coordination services to participants; and e. Provides management of the POC and facilitation of the team meetings. 5. Responsibility for Development of Person-Centered Service Plan. There are qualifications (that are reasonably related to developing service plans) for persons responsible for the development of the individualized, person-centered service plan. (Specify qualifications):

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 17 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 Participants in this State Plan HCBS benefit will participate in the Care Coordination model, facilitated by the CCO. Qualifications for Care Coordination Organizations (CCOs) are described in COMAR 10.09.90, and all 1915(i) participants are required to receive care coordination services under the same regulations. The State Plan Amendment pages for Care Coordination for Children and Youth include detailed requirements for CCOs. Care Coordinators employed by the CCO must demonstrate the following: i. Bachelor's degree and has met the Department’s training requirements for care coordinators; or ii. A high school diploma or equivalency and f. Is 21 years or older; and g. Was a participant in, or is a direct caregiver, or was a direct caregiver of an individual who received services from the public and child- and family-serving system; and h. Meets the training and certification requirements for care coordinators as set forth by the Department. i. Is employed by the CCO to provide care coordination services to participants; and j. Provides management of the POC and facilitation of the team meetings. iii. Care Coordinators may not be related by blood or marriage to the individual, or any paid caregiver of the individual, to whom they deliver care coordination services. The Clinical Director, a licensed mental health professional, will supervise the development and ongoing implementation of the POC and review and approve the POC. A core element of the Care Coordination model is the team approach. This team includes the CCO, child or youth (as appropriate), caregiver(s), support persons identified by the family (paid and unpaid), and service providers, including the youth’s treating clinician as available. The team should meet regularly and revisit the POC during meetings. There are a variety of assessments used to develop the POC, including information collected during the application process, and all life domains are incorporated into the POC. The Child and Adolescent Needs and Strengths (CANS) is administered every 90 days by the CCO supervisor to support identification of strengths and needs for care planning. Information from the family and their identified supports is incorporated as a part of the process 6. Supporting the Participant in Development of Person-Centered Service Plan. Supports and information are made available to the participant (and/or the additional parties specified, as appropriate) to direct and be actively engaged in the person-centered service plan development process. (Specify: (a) the supports and information made available, and (b) the participant’s authority to determine who is included in the process): The child's/youth's family is informed verbally and in writing about overall services available in the State Plan HCBS benefit at the time they make the choice to enroll. One of the key philosophies in the Care Coordination process is family-determined care. This means that parent(s) or legal guardian, youth and family members are the primary decision makers in the care of their family. The CCO is responsible for working with the participant, family, and team to develop the Plan of Care through the process outlined below.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 18 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 Within 72 hours of notification of enrollment, the Care Coordination Organization (CCO) contacts the participant and family to schedule a face-to-face meeting. At the first meeting between the CCO, participant, and family after enrollment, the CCO will: (a) Administer the appropriate assessments, as designated by the Behavioral Health Administration (BHA); (b) Work with the participant and family to develop an initial crisis plan that includes response to immediate service needs; (c) Provide an overview of the Care Coordination process; and (d) Facilitate the family sharing their story. The CCO will, with the participant and family: identify needs to work on in the planning process; determine team meeting attendees; contact potential team members, provide them with an overview of the Care Coordination process, and discuss expectations for the first team meeting; conduct a strengths based initial assessment of the participant, their family members and potential team members. Within 30 days of notification of enrollment, the CCO will offer the participant and family the opportunity to determine whether and how to use peer support in the development and implementation of the POC. The team, which includes the participant and his or her family and informal and formal supports will determine the family vision which will guide the planning process; identify strengths of the entire team; determine the needs that the team will be working on; determine outcome statements for meeting identified needs; determine the specific services and supports required in order to achieve the goals identified in the POC; create a mission statement that the team generates and commits to following; identify the responsible person(s) for each of the strategies in the POC; review and update the crisis plan; and, meet at least every 45 days to coordinate the implementation of the POC and update the POC as necessary. Before the provision of services in the POC, BHA or its designee shall review and authorize the services designated in the POC. The CCO in collaboration with the team shall reevaluate the POC at least every 45 days with re-administration of BHA-approved assessments as appropriate. During the development of the plan of care, family members and other supports identified by the family also participate as a part of the team. These participants may change as the child's or youth's needs change particularly as he/she is transitioning out of the formal care coordination services. The participant/family will sign and date a document that is part of the POC next to the statement that reads, “My family had voice and choice in the selection of services, providers and interventions, when possible, in the Care Coordination process of building my family's Plan of Care.” 7. Informed Choice of Providers. (Describe how participants are assisted in obtaining information about and selecting from among qualified providers of the 1915(i) services in the person-centered service plan): BHA or its designee will have and maintain a database and/or directory available to the CCO and the family from which to choose providers to implement the plan of care. Providers are selected by team with the support of the CCO. Participants are active members who will, depending on age and/or cognitive development, assist in the selection of providers based on the POC and the expertise of the team members. There will be an ongoing enrollment of providers to ensure the capacity is available.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 19 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 8. Process for Making Person-Centered Service Plan Subject to the Approval of the Medicaid Agency. (Describe the process by which the person-centered service plan is made subject to the approval of the Medicaid agency): Care Coordination is a team-level decision making process. The team determines the various supports and services that need to be in place for the family with the family and youth driving the process. The team is responsible to hold each other accountable in ensuring the implementation of high quality services for the family. The Care Coordination Organization (CCO) will manage the Plan of Care (POC). The Clinical Director, a licensed mental health professional employed by the CCO, will supervise the development and ongoing implementation of the POC and review and approve the POC. Prior to the provision of services in the POC, BHA or its designee will review and authorize the services designated in the POC based on medical necessity criteria for all Medicaid services. The POC will be provided to BHA or its designee to ensure that services that are authorized are consistent with the POC. Families have access to services made available in the 1915(i) and public mental health system that will address their individualized needs, as long as they meet medical necessity criteria. Families have the primary decision making responsibility around provider selection. If a family is dissatisfied with a provider, there is an internal process within the CCO to address these needs and mediate as well as transition to another provider when needed. This includes dissatisfaction with CCOs and any other providers. The POC process is designed to identify and address the individualized needs of each family. If a plan is not working for the family, the plan is revisited and redesigned to better meet the needs of the family. The team shares the philosophy that “the family doesn’t fail, the plan fails” and in turn needs to be re- developed. Families’ needs and strengths will be identified in part through the CANS as mentioned in the prior questions. The CCO is responsible for monitoring the implementation of plans of care by service providers. BHA will sample plans of care, review participant records, and track and trend the results of quality management activities as part of the quality assurance plan outlined below. BHA will document the results of ongoing monitoring activities on an as needed basis for reportable events reports, and annual reports, according to the quality improvement strategies, that are provided to the Medicaid Agency. The Medicaid Agency will review the quarterly and annual reports that are prepared by BHA. To address any service deficiencies, the Medicaid Agency will work in collaboration with BHA to implement any necessary changes to a participant’s plan of care, prepare letters to providers that document deficiencies, and impose provider sanctions as needed. 9. Maintenance of Person-Centered Service Plan Forms. Written copies or electronic facsimiles of service plans are maintained for a minimum period of 3 years as required by 45 CFR §74.53. Service plans are maintained by the following (check each that applies):

Medicaid agency

Operating agency

Case manager ; Other (specify): Care Coordination Organization Services 1. State plan HCBS. (Complete the following table for each service. Copy table as needed): Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover):

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 20 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 Service Title: Intensive In-Home Services Service Definition (Scope): Intensive In-Home Services (IIHS) is a strengths-based intervention with the child and his or her identified family (which may include biological family members, foster family members, treatment foster family members, or other individuals with whom the youth resides When approved for this service, the IIHS provider sees the family and/or youth at least once each week. IIHS includes a series of components, including functional assessments and treatment planning, individualized interventions, transition support, and in some cases, crisis response and intervention.

IIHS may be provided to the child alone, to other family members, and to the child and family members together. The services provided to other family members are essentialto the positive course of treatment of the youth enrolled in the program. Examples of this include strengthening a caregiver’s ability to manage challenging child behaviors, developing skills in setting appropriate boundaries with the child, and developing de-escalation skills that are necessary to stabilize the young person and the home setting. The IIHS treatment plan must be integrated with the overall POC, and the IIHS providers must work with the team and family to transition out of the intensive service.

IIHS is intended to support a child to remain in his or her home and reduce hospitalizations and out- of-home placements or changes of living arrangements through focused interventions in the home and community. Examples of situations in which IIHS may be used include at the start of a child’s enrollment in the HCBS benefit, upon discharge from a hospital or residential treatment center, or to prevent or stabilize after a crisis situation.

IIHS includes a crisis service component, with IIHS providers immediately available 24 hours per day, 7 days each week to provide services as needed to prevent, respond to, or mitigate a crisis situation. If the crisis cannot be defused,the IIHS provider is responsible for assisting the family in accessing emergency services immediately for that child. Additional needs-based criteria for receiving the service, if applicable (specify): N/A Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): ; Categorically needy (specify limits): The service is automatically authorized for 60 days for any individual meeting the eligibility criteria of this 1915(i) State Plan Amendment. Thereafter, the services will be authorized in six month increments. IIHS may not be billed on the same day as Mobile Crisis Response Services (MCRS), Mobile Treatment Services (MTS), partial hospitalization (day treatment), family therapy (not including individual therapy, medication management, or group therapy), an admission to an inpatient hospital or residential treatment center, or therapeutic behavioral services. The services provided under IIHS may not be duplicative of other Public Mental Health System or HCBS benefit services. ; Medically needy (specify limits):

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 21 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 Service limits are the same as those for the categorically needy. Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Intensive In- Home Health Occupations Article, Annotated Code of Maryland and COMAR 10.63.04 Certificate from national or intermediate purveyor All providers must have a certificate or letter from the national or intermediate purveyor or developer of the particular evidence-based practice or promising practice or from MDH to demonstrate that the provider meets all requirements for the specific type of Intensive In- Home Service, including but not limited to the requirements for quality assurance, auditing, monitoring, data collection and reporting, fidelity monitoring, participation in outcomes evaluation, training, and staffing, as outlined in regulation. MDH will maintain a publically available list of practices that meet the criteria for intensive in-home services, including but not limited to Family Centered Therapy (FCT) and Intervention Program For Children (IHIP-C). Providers of Intensive In-Home Services must ensure that 1) There are Clinical Leads, Supervisors, and Therapists on staff who are responsible for creating, implementing and managing the treatment plan with the child and family; and 2) For IIHS models including an on- call and crisis intervention element, these services, are: i) Provided by a licensed mental health professional (psychiatrist, psychologist, nurse psychotherapist (APRN- PMH), psychiatric nurse practitioner (CRNP- PMH) LCSW-C, LCSW, or

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 22 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 LCPC) trained in the intervention; and, ii) Available 24-hours per day, 7 days per week, during the hours the provider is not open to the individual enrolled in the treatment; and, iii) The program complies with staffing, supervision, training, data collection and fidelity monitoring requirements set forth by the purveyor, developer, or MDH and approved by the Department. 3) Clinical Leads and Supervisors must: a) Have a current license as either a licensed certified social worker- clinical (LCSW-C), licensed clinical professional counselor (LCPC), psychologist ,psychiatrist, nurse psychotherapists, or advanced practice registered nurse/psychiatric mental health (APRN/PMH) under the Health Occupations Article, Annotated Code of Maryland; and, b) Have at least three years of experience in providing mental health treatment to children and families. 4) Therapists must: a) Have either a current license as a licensed certified social worker (LCSW), LCSW-C, LCPC, psychologist, psychiatrist, nurse psychotherapist, or APRN/PMH under the Health Occupations Article, Annotated Code of Maryland; and b) Be supervised by a Clinical Lead or Supervisor; and

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 23 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 c) See the child in-person at least once in a seven (7) day period 5) In-home stabilizers a) Support the implementation of the treatment plan b) Must be at least 21 years old; c) Must have at least a high school diploma or equivalency; and d) Must have completed relevant, comprehensive, appropriate training prior to providing services, as outlined by the purveyor, developer, or MDH and approved by MDH.

Licensed mental health providers are subject to all the rules and regulations in the Maryland Health Occupations Article and to the oversight of their respective licensing boards. The IIHS provider may be a provider of Mobile Treatment Services, an Outpatient Mental Health Clinic, or a Psychiatric Rehabilitation Program for Minors Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Intensive In- Home Services BHA verifies provider approvals such as PRP, OMHC if applicable. BHA certifies programs not approved by BHA through its Administrative Service Organization At the time of application, and through a representative sample on an annual basis Service Delivery Method. (Check each that applies): † Participant-directed ; Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Community-Based Respite Care Service Definition (Scope): Community-Based Respite Services are temporary care services arranged on a planned or unplanned basis. Respite provides stabilization and relieves a caregiver from the stress of care giving. Unplanned respite may be provided on an emergency basis due to an unforeseen event, or to help

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 24 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 mitigate a potential crisis situation. These services may be provided in the home or the community. Community-based respite services are consistent with existing State of Maryland regulations for in- home respite care which is paid for using State-only dollars (COMAR 10.63.03.15). Respite care services are those that are: (1) Provided on a short-term basis in a community-based setting; and (2) Designed to support an individual to remain in the individual’s home by: (a) Providing the individual with enhanced support or a temporary alternative living situation, or (b) Assisting the individual’s home caregiver by temporarily freeing the caregiver from the responsibility of caring for the individual. Additionally, the respite services are designed to fit the needs of the individuals served and their caregivers. A program may provide respite care services as needed for an individual based on the Child/Youth and Family Team’s Plan of Care (POC). The specific treatment plan for the community-based respite care should outline the duration, frequency, and location and be designed with a planned conclusion. Additional needs-based criteria for receiving the service, if applicable (specify): N/A Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): ; Categorically needy (specify limits):

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 25 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 Community-based respite services are available to children receiving the HCBS benefit who are residing in his or her family home (biological or kin), legal guardian’s home, pre-adoptive/adoptive, or foster home. Community-based respite services do not include on-going day care or before or after school programs. Community-based respite services are not available to children residing in residential child care facilities (COMAR 14.31.05-.07) or treatment foster homes. The service is automatically authorized for 60 days for any individual meeting the eligibility criteria of this 1915(i) State Plan Amendment. Thereafter, the services will be authorized in six month increments. A minimum of one hour of the service must be provided to bill, up to a maximum of six hours per day. The services provided under Community-Based Respite Care may not be duplicative of other Public Mental Health System or HCBS benefit services, and will not be paid on the same day as therapeutic behavioral services (COMAR 10.09.34) or any other public mental health system respite services. The limit may be exceeded only by determination of need in accordance with the person- centered service plan and the participant directed budget. Individuals who may require services beyond the stated limit may work with their care coordinator and service provider to request additional service authorization by the ASO. The ASO will review the request for medical necessity and demonstrated need to extend the service beyond the limit, based on criteria developed by the Department. The limit on community-based respite is six hourly units allowed in a given day. Thus service provision that might exceed this daily limit may be a situation better suited to use of the out-of home respite service which can cover up to a 24 hour period. The two respite care services are treated as a continuum of options for providing caregivers with a break ; Medically needy (specify limits): Service limits are the same as those for the categorically needy. Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Community- Based Respite Care Health Occupations Article, Annotated Code of Maryland and COMAR 10.63.04 Certificate from national or intermediate purveyor Community Based Respite Care Providers Must: A. Meet the in-home respite care requirements of COMAR 10.63.03.15, as determined by the Maryland Department of Health; B. Ensure that respite care staff are: a. 21 years old or older and have a high school diploma or other high

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 26 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 school equivalency; or b. When providing services to participants under age 13, at least 18 years old and enrolled in or in possession of at least an associate or bachelor’s degree from an accredited school in a human service field. C. Ensure that community-based respite services are provided in the participant’s home or other community based setting; and, D. Follow the program model requirements outlined in COMAR 10.21.27.04-.08 for screening, assessment, staff training and expertise, provision of care, and conclusion of respite episode. Providers are approved by the Maryland Department of Health Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Community- Based Respite Care Administrative Service Organization on behalf of the Department BHA: At the time of enrollment and at least every three years ASO: At the time of enrollment and through a representative sample annually Service Delivery Method. (Check each that applies): † Participant-directed ; Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Out-of-Home Respite Service Definition (Scope): Out-of-Home Respite Services are temporary care which is arranged on a planned or unplanned basis. Respite provides stabilization and relieves a caregiver from the stress of care-giving. Unplanned respite may be provided on an emergency basis due to an unforeseen event, or to help mitigate a potential crisis situation. Out-of-home respite is provided in community-based alternative living arrangements that are appropriately licensed, registered, or approved, based on the age of individuals receiving services, and whether the respite has capacity to do overnight services. Out-of-home respite

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 27 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 services may not be provided in an institutional setting or on a hospital or residential facility campus. The services provided under Out-of-Home Respite Care may not be duplicative of other Public Mental Health System or HCBS benefit services. Additional needs-based criteria for receiving the service, if applicable (specify): N/A Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): ; Categorically needy (specify limits): Out-of-Home respite services only are available to children receiving the HCBS benefit who are residing in his or her family home (biological or kin), legal guardian’s home, pre- adoptive/adoptive, or foster home. Out-of-home respite services are not available to children residing in residential child care facilities (COMAR 14.31.05-.07) or treatment foster homes. Out-of-home respite services do not include ongoing day care or before or after school programs. The service is automatically authorized for a 60 day period after enrollment for any individual meeting the eligibility criteria of this 1915(i) State Plan Amendment. This is not to say that the Out-of-home respite episode would be 60 days in duration, as it is generally offered as a single overnight or in some cases,as a weekend of respite care for a family. After this initial 60-day period, the services will be authorized in six month increments. Out- of-home respite must be provided in a community-based alternative living arrangement outside of the child’s home and must be provided for a minimum of twelve hours overnight in order to bill. Participants may receive a maximum of 24 overnight units of out-of-home respite services annually. This limit is based on the framework of up to one weekend of respite care in a given month, or similar reasonable configuration. The limit may be exceeded only by determination of need in accordance with the person- centered service plan and the participant directed budget. Individuals who may require services beyond the stated limit may work with their care coordinator and service provider to request additional service authorization by the ASO. The ASO will review the request for medical necessity and demonstrated need to extend the service beyond the limit, based on criteria developed by the Department. ; Medically needy (specify limits): Service limits are the same as those for the categorically needy. Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Out-of-Home Respite Health Occupations Article, Annotated Code Certificate from national or intermediate purveyor Out-of-Home Respite Care Providers must: A. Meet the out-of-home respite care requirements of COMAR 10.63.03, as determined by

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 28 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 of Maryland and COMAR 10.63.04 the Maryland Department of Health. B. Ensure that respite care staff are: a. 21 years old or older and have a high school diploma or other high school equivalency; or b. When providing services to participants under age 13, at least 18 years old and enrolled in an accredited post- secondary educational institution or in possession of at least an associate or bachelor's degree from an accredited school in a human services field. C. Ensure that out-of-home respite services are provided in a community-based alternative living arrangement outside the participant’s home, in accordance with COMAR 14.31.05-.07, where applicable. D. Follow the program model requirements outlined in COMAR 10.63.04.15 for screening, assessment, staff training and expertise, provision of care, and conclusion of respite episode.

Providers are approved by the Maryland Department of Health. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Out-of-Home Respite Care BHA initial verification of license or approval Administrative Service Organization on behalf of the Department BHA: At the time of enrollment and at least every three years ASO: At the time of enrollment and

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 29 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 through a representative sample annually Service Delivery Method. (Check each that applies): † Participant-directed ; Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Family Peer Support Service Definition (Scope): Family Peer Support is delivered on an individualized basis by a Peer Support Partner with lived experience who will do some or all of the following, depending on the Plan of Care developed by the CCO, Care Coordinator, and family. These services are specifically supportive of parents and caregivers rather than the child in need and contribute to the overall POC implementation. These services designed to assist families who would otherwise have difficulty engaging the care coordination/treatment process due to a history of accumulated negative experiences with the system which act as a barrier to engagement. The family peer support specialist employed by the Family Support Organization (FSO) : x Participate as a member of the Child/Youth Family Team meetings • Explain role and function of the FSO to newly enrolled families and at the direction of the CCO linkages to other peers and supports in the community • Work with the family to identify and articulate their concerns, needs,and vision for the future of their child; and ensure family opinions and perspectives are incorporated into Child/Youth Family Team process and Plan of Care through communication with CCO and Team Members • Attend Child/Youth Family Team meetings with the family to support family decision making and choice of options • Listen to the family express needs and concerns from peer perspective and offer suggestions for engagement in the care coordination process • Provide ongoing emotional support, modeling and mentoring during all phases of the Child/Youth Family Team process • Help family identify and engage its own natural support system • Facilitate the family attending peer support groups and other FSO activities throughout POC process • Work with the family to organize, and prepare for meetings in order to maximize the family’s participation in meetings • Inform the family about options and possible outcomes in selecting services and supports so they are able to make informed decisions for their child and family • Support the family in meetings at school and other locations in the community and during court hearings • Empower the family to make choices to achieve desired outcomes for their child or youth, as well as the family • Through one-to-one training, help the family acquire the skills and knowledge needed to attain greater self- sufficiency and maximum autonomy. • Assist the family in developing the skills and confidence to independently identify, seek out and access resources that will assist in managing and mitigating the child/youth’s behavioral

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 30 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 health condition(s), preventing the development of secondary or other chronic conditions, promoting optimal physical and behavioral health, and addressing and encouraging activities related to health and wellness • Assist in identifying and securing formal and informal resources for the family • Assist the family in organizing and completing paperwork to secure needed resources • Educate the family on how to navigate systems of care for their children • Conduct an assessment related to the need for peer support (including projected frequency and duration) communicate with CCO and other team members Additional needs-based criteria for receiving the service, if applicable (specify): N/A Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): ; Categorically needy (specify limits): The service is automatically authorized for one year for any individual meeting the eligibility criteria of this 1915(i) State Plan Amendment. Thereafter, the services will be authorized in six month increments. The services provided under Family Peer Support may not be duplicative of other Public Mental Health System or HCBS benefit services. Family peer support may be provided, and billed, for meeting with the family in-person as well as for communicating with the family over the phone. Family peer support may not be billed for telephonic communications with other providers or resources. Service limits for peer support as follows: Face to face family support limited to 11 hours per month and telephonic peer support limited to 16 hrs monthly, unless specially approved by BHA for higher levels. ; Medically needy (specify limits): Service limits are the same as those for the categorically needy. Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Family Peer Support N/A The National Certification for Parent Family Peers. The provider may have the certificate, be in the process of obtaining it or under the supervision of an individual Family peer support must be provided by a Family Support Organization (FSO). To be eligible to provide services as an FSO, the organization must: (1) Be a private, non-profit entity designated under 501(c)(3) of the Internal Revenue Service Code, and submit copies of the certificate of incorporation and Internal Revenue Service designation; (2) Submit a list of members of the

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 31 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 who has the certification. board of directors with identification that at least 50% meet the following criteria: a) Are caregivers with a current or previous primary daily responsibility for raising a child or youth with behavioral health challenges; and/or b) Are individuals who have experience with State or local services and systems as a consumer who has or had behavioral health challenges (3) Establish hiring practices that give preference to current or previous caregivers of youth with behavioral health challenges and/or individuals who have experience with State or local services and systems as a consumer who has or had behavioral health challenges, and submit a copy of the organization’s personnel policy that sets forth this preferred employment criteria; (4) Employ a staff that is comprised of at least 75% individuals who are current or previous caregivers of youth with behavioral health challenges, or are individuals who have experience with State or local services and systems as a consumer who has or had emotional, behavioral health challenges, and submit a list of staff and positions held with identification of those who fit the experienced caregiver and consumer criteria; and (5) Maintain generalliability insurance to provide family peer support, the peer support provider shall: (1) Be employed by a Family Support Organization; (2) Be at least 18 years old; (3) Receive supervision from an individual who is at least 21 years old and has at least three years of

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 32 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 experience providing family peer support or working with children with serious behavioral health challenges and their families; (4) Have current or prior experience as a caregiver of a child with behavioral health challenges or be an individual with experience with State or local services and systems as a consumer who has or had behavioral health challenges ; and Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Family Peer Support Administrative Service Organization on behalf of the Department BHA: At the time of enrollment and at least every three years ASO Service Delivery Method. (Check each that applies): † Participant-directed ; Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Expressive and Experiential Behavioral Services Service Definition (Scope): Expressive and Experiential Behavioral Services are adjunct therapeutic modalities to support individualized goals as part of the plan of care. These services involve action on the part of the provider and the participant. The aim of creative therapeutic modalities is to help participants find a form of expression beyond words or traditional therapy. They include techniques that can be used for self-expression and personal growth and aid in the healing and therapeutic process. Experiential and Expressive Therapeutic Services include the following, and may include other specific service types if they meet MDH’s standards for training, certification, and accountability: • Art Behavioral Services • Dance/Movement Behavioral Services • Equine-Assisted Behavioral Services • Horticultural Behavioral Services • Music Behavioral Services • Drama Behavioral Services Additional needs-based criteria for receiving the service, if applicable (specify): N/A Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 33 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): ; Categorically needy (specify limits): Expressive and Experiential Behavioral Service Providers must receive prior authorization from the Administrative Service Organization for these services before providing them to participants. Participants may receive a maximum of two different expressive and experiential behavioral services on the same day. ; Medically needy (specify limits): Service limits are the same as those for the categorically needy. Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Expressive and Experiential Behavioral Service Providers N/A Board Certified Therapeutic Provider per specific therapeutic discipline Programs are approved by the Maryland Department of Health. Licensed mental health providers are subject to all the rules and regulations in the Maryland Health Occupations Article and to the oversight of their respective licensing boards.

To provide a particular expressive and experiential behavioral service,an individual shall have: (a) A bachelor’s or master’s degree from an accredited college or university; and (b) Current registration in the applicable certification body. The Department of Health and Mental Hygiene will maintain a publicly available list of Certification Bodies. The provider organization must maintain general liability insurance Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Expressive and experiential Behavioral Service Administrative Service Organization on behalf of the Department At the time of application and annually Service Delivery Method. (Check each that applies): † Participant-directed ; Provider managed

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 34 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 2. † Policies Concerning Payment for State plan HCBS Furnished by Relatives, Legally Responsible Individuals, and Legal Guardians. (By checking this box the state assures that): There are policies pertaining to payment the state makes to qualified persons furnishing State plan HCBS, who are relatives of the individual. There are additional policies and controls if the state makes payment to qualified legally responsible individuals or legal guardians who provide State Plan HCBS. (Specify (a) who may be paid to provide State plan HCBS; (b) the specific State plan HCBS that can be provided; (c) how the state ensures that the provision of services by such persons is in the best interest of the individual; (d) the state’s strategies for ongoing monitoring of services provided by such persons; (e) the controls to ensure that payments are made only for services rendered; and (f) if legally responsible individuals may provide personal care or similar services, the policies to determine and ensure that the services are extraordinary (over and above that which would ordinarily be provided by a legally responsible individual):

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 35 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 Participant-Direction of Services Definition: Participant-direction means self-direction of services per §1915(i)(1)(G)(iii). 1. Election of Participant-Direction. (Select one): z The state does not offer opportunity for participant-direction of State plan HCBS. { Every participant in State plan HCBS (or the participant’s representative) is afforded the opportunity to elect to direct services. Alternate service delivery methods are available for participants who decide not to direct their services. { Participants in State plan HCBS (or the participant’s representative) are afforded the opportunity to direct some or all of their services, subject to criteria specified by the state. (Specify criteria): 2. Description of Participant-Direction. (Provide an overview of the opportunities for participant- direction under the State plan HCBS, including: (a) the nature of the opportunities afforded; (b) how participants may take advantage of these opportunities; (c) the entities that support individuals who direct their services and the supports that they provide; and, (d) other relevant information about the approach to participant-direction): 3. Limited Implementation of Participant-Direction. (Participant direction is a mode of service delivery, not a Medicaid service, and so is not subject to statewideness requirements. Select one): { Participant direction is available in all geographic areas in which State plan HCBS are available. { Participant-direction is available only to individuals who reside in the following geographic areas or political subdivisions of the state. Individuals who reside in these areas may elect self- directed service delivery options offered by the state, or may choose instead to receive comparable services through the benefit’s standard service delivery methods that are in effect in all geographic areas in which State plan HCBS are available. (Specify the areas of the state affected by this option): 4. Participant-Directed Services. (Indicate the State plan HCBS that may be participant-directed and the authority offered for each. Add lines as required): Participant-Directed Service Employer Authority Budget Authority † † † † 5. Financial Management. (Select one) : z Financial Management is not furnished. Standard Medicaid payment mechanisms are used. { Financial Management is furnished as a Medicaid administrative activity necessary for administration of the Medicaid State plan.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 36 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 6. † Participant–Directed Person-Centered Service Plan. (By checking this box the state assures that): Based on the independent assessment required under 42 CFR §441.720, the individualized person- centered service plan is developed jointly with the individual, meets federal requirements at 42 CFR §441.725, and: x Specifies the State plan HCBS that the individual will be responsible for directing; x Identifies the methods by which the individual will plan, direct or control services, including whether the individual will exercise authority over the employment of service providers and/or authority over expenditures from the individualized budget; x Includes appropriate risk management techniques that explicitly recognize the roles and sharing of responsibilities in obtaining services in a self-directed manner and assures the appropriateness of this plan based upon the resources and support needs of the individual; x Describes the process for facilitating voluntary and involuntary transition from self-direction including any circumstances under which transition out of self-direction is involuntary. There must be state procedures to ensure the continuity of services during the transition from self-direction to other service delivery methods; and x Specifies the financial management supports to be provided.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1–i: TN: 19-0003 Page 37 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 7. Voluntary and Involuntary Termination of Participant-Direction. (Describe how the state facilitates an individual’s transition from participant-direction, and specify any circumstances when transition is involuntary): 8. Opportunities for Participant-Direction a. Participant–Employer Authority (individual can select, manage, and dismiss State plan HCBS providers). (Select one): z The state does not offer opportunity for participant-employer authority. { Participants may elect participant-employer Authority (Check each that applies): † Participant/Co-Employer. The participant (or the participant’s representative) functions as the co-employer (managing employer) of workers who provide waiver services. An agency is the common law employer of participant-selected/recruited staff and performs necessary payroll and human resources functions. Supports are available to assist the participant in conducting employer-related functions. † Participant/Common Law Employer. The participant (or the participant’s representative) is the common law employer of workers who provide waiver services. An IRS-approved Fiscal/Employer Agent functions as the participant’s agent in performing payroll and other employer responsibilities that are required by federal and state law. Supports are available to assist the participant in conducting employer-related functions. b. Participant–Budget Authority (individual directs a budget that does not result in payment for medical assistance to the individual). (Select one): z The state does not offer opportunity for participants to direct a budget. { Participants may elect Participant–Budget Authority. Participant-Directed Budget. (Describe in detail the method(s) that are used to establish the amount of the budget over which the participant has authority, including the method for calculating the dollar values in the budget based on reliable costs and service utilization, is applied consistently to each participant, and is adjusted to reflect changes in individual assessments and service plans. Information about these method(s) must be made publicly available and included in the person-centered service plan.): Expenditure Safeguards. (Describe the safeguards that have been established for the timely prevention of the premature depletion of the participant-directed budget or to address potential service delivery problems that may be associated with budget underutilization and the entity (or entities) responsible for implementing these safeguards.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 19-0003 Page 38 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 Quality Improvement Strategy Quality Measures (Describe the state’s quality improvement strategy. For each requirement, and lettered sub-requirement, complete the table below): 1. Service plans a) address assessed needs of 1915(i) participants; b) are updated annually; and (c document choice of services and providers. 2. Eligibility Requirements: (a) an evaluation for 1915(i) State plan HCBS eligibility is provided to all applicants for whom there is reasonable indication that 1915(i) services may be needed in the future; (b) the processes and instruments described in the approved state plan for determining 1915(i) eligibility are applied appropriately; and (c) the 1915(i) benefit eligibility of enrolled individuals is reevaluated at least annually or if more frequent, as specified in the approved state plan for 1915(i) HCBS. 3. Providers meet required qualifications. 4. Settings meet the home and community-based setting requirements as specified in this SPA and in accordance with 42 CFR 441.710(a)(1) and (2). 5. The SMA retains authority and responsibility for program operations and oversight. 6. The SMA maintains financial accountability through payment of claims for services that are authorized and furnished to 1915(i) participants by qualified providers. 7. The state identifies, addresses, and seeks to prevent incidents of abuse, neglect, and exploitation, including the use of restraints. (Table repeats for each measure for each requirement and lettered sub-requirement above.)

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 19-0003 Page 39 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 Discovery Activities Remediation Requirement Discovery Evidence (Performance Measures) Discovery Activity (Source of Data & sample size) Monitoring Responsibilities (agency or entity that conducts discovery activities)

Frequency Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation)

Frequency of Analysis and Aggregation 1) Service plans address a) assessed needs of 1915(i) participants, b) are updated annually, and c) document choice of services and providers. a) % of participants who had a team meeting at least every 45 days

b) % of participants whose plan of care (POC) was updated to include change in progress, services or other areas within ten (10) days of the team meeting 1. Defensible sample of case files (electronic or paper) of participants who were enrolled during the time period under review 2. Review of all POC during identified time period for a defensible sample of participants who were enrolled during the time period under review 1. MDH/BHA, with CSAs/ LBHAs

2. MDH/BHA with CSAs/ LBHAs 1. Every 12 months

2. Every 12 months 1. MDH/BHA with CSAs/ LBHAs

2. MDH/BHA with CSAs/ LBHAs If a performance improvement plan is needed, a program director must submit a proposal within 10 working days. The final performance improvement plan must be submitted to BHA, ASO, and CSA, as applicable, within 30 working days of notice of program deficiencies. The CSA will follow up with the program 3 months after the final implementation of the performance improvement plan.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 19-0003 Page 40 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 c) % of participants whose POC indicates they were afforded choice in the selection of services and providers 3. Review of all POC during identified time period for a defensible sample of participants who were enrolled during the time period under review 3. MDH/BHA with CSAs/ LBHAs 3. Every 12 months 3. MDH/BHA with CSAs/ LBHAs

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 19-0003 Page 41 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 3) Providers meet required qualifications. a) % of providers who have submitted 1915(i) HCBS claims who are approved as providers by Maryland Medicaid b) % of providers who meet the initial and ongoing requirements established by MDH/BHA 1 & 2. Defensible sampling strategy of provider files and related documentatio n. The sample will be drawn from providers who filed claims for services provided under the HCBS benefit during the time period under review. 1 & 2. ASO Annually MDH/BHA If a performance improvement plan is needed, a program director must submit a proposal within 10 working days. The final performance improvement plan must be submitted to BHA within 30 working days of notice of program deficiencies. The CSA will follow up with the program 3 months after the final implementation of the performance improvement plan.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 19-0003 Page 42 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 4) Settings meet the home and community- based setting requirements as specified in this SPA. 1. % of youth who are dis-enrolled as a result of moving to a setting that is not authorized in this SPA. 1. Semi-annual sampling of entire enrolled roster 1. MDH/ BHA with the CSAs/ LBHAs Semi-Annually MDH/BHA Based on the findings, OHS and BHA will create a performance improvement plan within 30 working days of identification of deficiencies

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 19-0003 Page 43 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 5) The SMA retains authority and responsibility for program operations and oversight. a) % of quarterly progress reports submitted to MDH/Office of Health Services b) % of enrollment census updates distributed to OHS c) Medical Eligibility/enrollme nt Oversight 1. Quarterly reports are provided to OHS by BHA 2. Review of distribution list for census updates issued by BHA 3. Review CASII/CONS documentation 1&2. MDH/BHA 3. ASO/BHA Annually MDH/BHA& MDH/OHS Based on the findings, MDH and BHA will create a performance improvement plan within 30 working days of identification of deficiencies.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 19-0003 Page 44 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 6) The SMA maintains financial accountability through payment of claims for services that are authorized and furnished to 1915(i) participants by qualified providers. 1. % of HCBS benefit service claims processed appropriately against fund source, authorization history, service limitations, and coding. 2. % of participants with completed financial eligibility reviews in accordance with policy at initial and redetermination (to include Medical Assistance eligibility and Level of Intensity documentation). Defensible sampling strategy; point in time review of services received. MDH/ASO Annually MDH/BHA If a performance improvement plan is needed, a program director must submit a proposal within 10 working days. The final performance improvement plan must be submitted to BHA within 30 working days of notice of program deficiencies. The CSA will follow up with the program 3 months after the final implementation of the performance improvement plan. The Office of Compliance is a unit within the BHA responsible for identifying fraud and abuse, educating providers about compliance issues, and ensuring consistency with State and federal regulations. BHA may direct the ASO to retract paid claims, and may refer noncompliant providers to the Office of the Inspector General or Medicaid Fraud Unit with the Attorney General’s Office. BHA participates with the Office of Inspector General to identify provider outliers for investigation of potential fraud and abuse.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 19-0003 Page 45 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 7) The state identifies, addresses and seeks to prevent incidents of abuse, neglect, exploitation, including the use of restraints, and unexplained deaths. % of reportable events involving abuse, neglect, exploitation, and/or unexplained deaths reported that are resolved according to policy All reportable event forms are reviewed for compliance. MDH/BHAAnnually, and continuously , as needed when a complaint/in cident is received. MDH/B HA MDH will investigate if a performance improvement plan is needed. If necessary, the program director must submit a proposal within 10 working days. 2) Eligibility Requirements – a) an evaluation for 1915(i) State Plan HCBS eligibility is provided to all applicants for whom there is reasonable indication that 1915(i) services may be needed in the future; Utilization review of services on POC in conjunction with provider authorization and claims data Review of all POC during identified time period for a defensible sample of participants who were enrolled during the time period under review ASO Semi- Annually MDH/BHA with ASO & CSAs Based on the findings, MDH and BHA will create a performance improvement plan within 30 working days of identification of deficiencies.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 19-0003 Page 46 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 b) The process and instruments the processes and instruments described in the approved state plan for determining 1915(i) eligibility are applied appropriately, and Number of participants who meet all eligibility criteria. Review of all POC and referral forms uploaded into the ASO’s system during identified time period for a defensible sample of participants who were enrolled d i h i ASO Semi- Annually MDH/BHA with ASO & CSAs Based on the findings, MDH and BHA will create a performance improvement plan within 30 working days of identification of deficiencies. c) the 1915(i) benefit eligibility of enrolled individuals is reevaluated at least annually or if more frequent, as specified in the state plan for 1915(i) HCBS. Percent of participants who were re-evaluated for eligibility after one year. Review authorization data for participants who were continually enrolled for one year from the sample. ASO Semi- annually MDH Based on the findings, MDH and BHA will create a performance improvement plan within 30 working days of identification of deficiencies.

State: Maryland §1915(i) State plan HCBS State plan Attachment 3.1-i: TN: 19-0003 Page 47 Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 14-05 System Improvement (Describe the process for systems improvement as a result of aggregated discovery and remediation activities.) System Improvement: (Describe process for systems improvement as a result of aggregated discovery and remediation activities.) Methods for Analyzing Data and Prioritizing Need for System Improvement Roles and Responsibilities Frequency Method for Evaluating Effectiveness of System Changes When data analysis reveals the need for system change, recommendations may be made along with a prioritization of design changes. Plans developed as a result of this process will be shared with stakeholders. All issues related to health, welfare, and safety will be prioritized above all else. Some issues may be monitored for a period of time if they do not threaten the health, welfare, or safety of participants and do not impede the State’s ability to receive federalfinancial participation.

MDH, BHA, in conjunction with the ASO and the CSAs, will gather and analyze the data and identify areas for quality improvement.

Annually The Department or its designee will examine prior year data and examine data, to the extent it is available, on the functional outcomes of youth served through the HCBS Benefit, particularly with regard to remaining in or returning to a family-living environment, attending school or work, and not having future involvement with the juvenile justice or adult corrections systems. There will also be a focus on the comprehensive cost of care for youth enrolled in the HCBS benefit and served by the CCOs, as well as the psychotropic medication prescribing for these youth and their access to physical and oral health care services.

State: Maryland §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: 19-0003

Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 16-0007 Methods and Standards for Establishing Payment Rates 1. Services Provided Under Section 1915(i) of the Social Security Act. For each optional service, describe the methods and standards used to set the associated payment rate. (Check each that applies, and describe methods and standards to set rates):

HCBS Case Management

HCBS Homemaker

HCBS Home Health Aide

HCBS Personal Care

HCBS Adult Day Health

HCBS Habilitation ; HCBS Respite Care

State: Maryland §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: 19-0003

Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 16-0007 COMMUNITY-BASED RESPITE CARE

Community-based respite services are provided for a minimum of one hour and a maximum of six hours per day, and may not be billed on the same day as out of home respite. These are paid using a service unit of one hour. Assumptions 68% billable time Respite Care worker has caseload of 15 Hourly rate is added to hourly pay for respite care worker of $13/hour Additional $1 youth activity fee per hour is added to total Payment for Community Based Respite Care service as outlined per Attachment 3.1-i pa 24-25 and is reimbursed at an hourly unit of service. Community Based Respite Care providers are defined per Attachment 3.1-i page 25-26.

The agency's fee schedule was set as of October 1, 2014 and is effective for services provided on or after that date. All rates are published on the agency's website at https://mmcp.health.maryland.gov/pages/1915(i)-Intensive-Behavioral-Health-Services Annual Amount or Rate % FT E

Salary Cost Fringe Benefits (30%)

Salary + Fringe Cost Respite Supervisor $50,000.00 0.10 $5,000.00 $1,500.00 $6,500.00 Admin. Support $35,000.00 0.05 $1,750.00 $525.00 $2,275.00 Total 0.15 $6,750.00 $2,025.00 $8,775.00 Other Costs (based on FTE) Rent (144 Square Feet @ $15 per square foot per FTE) $ 324.00 Cellular Phone, Internet & Communications (@$110/month per FTE)

$ 198.00 Mileage (10,000 miles per year @ $0.555/mile) $ 5,550.00 Insurance (generalliability, professional liability) @$1,000 per FTE

$ 150.00 Indirect Cost (7% of salaries) $ 472.50 Total cost for 1 FTE respite care worker $ 15,469.50 Hourly Rate--Not Including Respite Care Worker (Based on 1386 h ) $ 11.16 Hourly Rate for Administration + Respite Care Worker + $1 h A i i Activity Fee $ 25.16 State developed fee schedule rates are the same for both governmental and private individual practitioners and the fee schedule and any annual/periodic adjustments to the schedule are published at the above website address.

State: Maryland §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: 19-0003

Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 16-0007

OUT OF HOME RESPITE CARE Out of Home respite services are provided on an overnight basis for a minimum of 12 hours, and are reimbursed using a flat per diem rate. The service has a maximum of 24 units per year, subject to medical necessity criteria override. The service may not be bill on the same day as community-based respite. Out-of-Home Respite Median per diem rate for 109 "preferred" programs 181.31 10% Administrative Charge 18.13 Total 199.44 The rate development is based on the Fiscal Year 2012 Maryland Interagency Rates Committee (IRC) rates for residential child care facilities and child placement agencies. The IRC is charged with developing and operating a rate process for residential child care and child placement agency programs that is fair, equitable and predictable, and is comprised of representatives from the Department of Budget and Management, Maryland Department of Health Administration/Behavioral Health Administration, Department of Human Resources/SocialServices Administration, Department of Juvenile Services, Governor's Office for Children and the Maryland State Department of Education (http://www.marylandpublicschools.org/MSDE/divisions/earlyinterv/IRC). The IRC identifies programs as "preferred" or "non-preferred." For this rate development, only preferred provider rates were incorporated. Additionally, only the per diem rates for group homes, therapeutic group homes, and treatment foster care providers were included.

The fiscal model identified in the August 2006 Real Choice Systems Change Grants for Community Living: A Feasibility Study to Consider Respite Services for Children with Disabilities in Maryland prepared by The Hilltop Institute (formerly the Center for Health Program Development and Management) at UMBC included a 10% administrative cost for training, family support, outreach and provider recruitment that was specific to the youth at the highest levels of care. A similar finding of a need for additional administrative funds was identified by the Respite Care Committee under the Maryland Blueprint for Children's Mental Health Committee.

Payment for Out Of Home Respite Care service as outlined per Attachment 3.1-i page 24- 25 and is reimbursed at an hourly unit of service. Out Of Home Respite Care providers are defined per Attachment 3.1-i page 25-26.

The agency's fee schedule was set as of October 1, 2014 and is effective for services provided on or after that date. All rates are published on the agency's website at https://mmcp.health.maryland.gov/pages/1915(i)-Intensive-Behavioral-Health-Services-for-Children,- Youth-and-Families.aspx State developed fee schedule rates are the same for both governmental and private individual practitioners and the fee schedule and any annual/periodic adjustments to the fee schedule are published at the above website address

State: Maryland §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: 19-0003

Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 16-0007 For Individuals with Chronic Mental Illness, the following services:

HCBS Day Treatment or Other Partial Hospitalization Services ; HCBS Psychosocial Rehabilitation

State: Maryland §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: 19-0003

Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 16-0007 Intensive In-Home Services (IIHS) – EBP

Personnel Annual Amount or Rate % FT E

Salary Cost Fringe Benefits (25%)

Salary + Fringe Cost

Therapist

$ 50,000

1

$ 50,000

$ 12,500 $ 62,500.00 Supervisor/Clinical Lead

$ 75,000

0.20

$ 15,000

$ 3,750 $ 18,750.00

Clinical Director

$ 100,000

0.09

$ 9,000

$ 2,250 $ 11,250.00 Quality Assurance/Management Info. Systems Director

$ 90,000

0.09

$ 8,100

$ 2,025

$ 10,125.00

Admin. Assistant

$ 35,000

0.25

$ 8,750

$ 2,188 $ 10,937.50 Billing Support Specialist $ 35,000 0.05 $ 1,750 $ 438 $ 2,187.50 Total 1.68 $ 92,600 $ 23,150 $ 115,750 Rent ($15/sq ft, 144 sq ft per FTE) Cellular Phone, Internet & Communications (@$110/month per FTE)

$ 2,217.60 Office supplies and maintenance (paper, postage, pens, printing, copier/fax) @ $750 per FTE

$ 1,260.00 Mileage (20,000 miles per year @ $0.555/mile) $ 11,100.00 Management Information System @$150 per FTE $ 252.00 Insurance (generalliability, professional liability) @ $1,000 per FTE

$ 1,680.00 Indirect Cost (7% of salaries) $ 6,482.00 Total Cost for 1 FTE Therapist $ 142,370.40 Weekly rate (Total Cost/52 weeks/11 clients) $ 248.90

Assumptions: Supervisor caseload of 5 therapists Maximum length of service is 16 weeks Intensive In-Home Services (IIHS) providers may be reimbursed at a regular weekly rate of service. The approved IIHS providers will bill the Maryland Department of Health directly for the services rendered. No more than one unit of service may be billed for services delivered at the same time by the same staff. Private and public IIHS providers will be reimbursed at the same rate. The rate development adheres to the CMS-accepted methodology for cost-based rates, which includes salary, fringe benefits, indirect costs, and transportation costs based on an average of the mileage experience in current IIHS program. Cost estimates conform to our

State: Maryland §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: 19-0003

Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 16-0007 experience with programs similar to IIHS in Maryland, including the salaries paid. An IIHS provider may bill for a week only if an IIHS activity occurred for the covered youth on at least one day of the billable week. A minimum of one (1) face- to-face contact is required per week. At least fifty percent (50%) of therapist’s contacts with the youth and/or family must be face-to-face. A minimum of fifty percent (50%) of the therapist’s time must be spent working outside the agency and in the youth’s home or community, as documented in the case notes. An individual can only receive IIHS services from one provider at a time. Partial hospitalization/day treatment, mobile crisis response services (MCRS), and other family therapies cannot be charged at the same time. IIHS providers are expected to provide crisis response services for the youth on their caseload. An evidence-based practice (EBP) is defined as a program, intervention or service that: 1. is recognized by MDH as an EBP for youth; a. are derived from rigorous, scientifically controlled research; and b. can be applied in community settings with a defined clinical population; 2. has a consistent training and service delivery model; 3. utilizes a treatment manual; and 4. has demonstrated evidence that successful program implementation results in improved, measureable outcomes for recipients of the service intervention. The rate is higher for those programs that are identified as an EBP, in keeping with the established practice of different reimbursement rates for an EBP versus non-EBP service (e.g., Mobile Treatment Services and Assertive Community Treatment). The weekly rate for the IIHS-EBP program is based on the cost of a therapist with a maximum caseload of 11 and a maximum length of stay in the program of 16 weeks. The supervisor caseload is a ratio of 1:5. The rate includes other costs, including mileage costs (at least 50% of face-to-face contacts must be in the home or community, and the therapist must see the youth and family face-to-face at least once each week), rent, and communications costs. Payment for Intensive In-Home service as outlined per Attachment 3.1-i page 15-16 and is reimbursed a weekly unit of service. Intensive In-Home providers are defined per Attachment 3.1-i page 16-19. The agency's fee schedule was set as of October 1, 2014 and is effective for services provided on or after that date. All rates are published on the agency's website at https://mmcp.health.maryland.gov/pages/1915(i)-Intensive-Behavioral-Health-Services-for- Children,-Youth-and-Families.aspx State developed fee schedule rates are the same for both governmental and private individual practitioners and the fee schedule and any annual/periodic adjustments to the fee schedule are published at the above website address. Intensive In-Home Services (IIHS)- NON EBP

State: Maryland §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: 19-0003

Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 16-0007

Personnel

Annual Amount or Rate

% FT E

Salary Cost Fringe Benefit s (25%)

Salary + Fringe Cost

Therapist

$ 50,000

0.50

$ 25,000 $ 6,250

$ 31,250.00 Supervisor/Clinical Lead

$ 75,000

0.20

$ 15,000 $ 3,750

$ 18,750.00

In-Home Stabilizer

$ 40,000

0.50

$ 20,000 $ 5,000

$ 25,000.00

Clinical Director $ 100,000

0.08

$ 8,000 $ 2,000

$ 10,000.00

Admin. Assistant

$ 35,000

0.25

$ 8,750 $ 2,188

$ 10,937.50 Billing Support Specialist

$ 35,000

0.05

$1,750

$ 438

$ 2,187.50 Total l 1.58 $78.500 $ 78 500 $19,62 5 $ 98,125 Other Costs Rent ($15/sq ft, 144 sq ft per FTE) $ 3,412.80 Cellular Phone, Internet & Communications (@$110/month per FTE)

$ 2,085.60 Office supplies & maintenance (paper, postage, pens, printing, copier/fax) @ $750 per FTE

$ 1,185.00 Mileage (20,000 miles per year @ $0.555/mile) $ 11,100.00 Management Information System @$150 per FTE $ 237.00 Insurance (generalliability, professional liability) @$1,000 per FTE

$ 1,580.00 Indirect Cost (7% of salaries) $ 5,495.00 Total Cost FTE $ 123,220.40 Weekly rate (total cost/(52*12)) $ 197.47 Assumptions: Caseload of 12 clients Supervisor caseload of 5 therapists Youth may stay in for a year Clients are supported by .5 FTE therapist, .5FTE in-home stabilizer, .2 supervisor/cli lead, and .08 clinical director Intensive In-Home Services (IIHS) providers may be reimbursed at a regular weekly rate of service. The approved IIHS providers will bill the Maryland Department of Health directly for the services rendered. No more than one unit of service may be billed for services delivered at the same time by the same staff. Private and public IIHS providers will be reimbursed at the same rate. The rate development adheres to the CMS-accepted methodology for cost-based rates, which includes salary, fringe benefits, indirect costs, and transportation costs based on an average of the mileage experience in current IIHS program. Cost estimates conform to our experience with programs similar to IIHS in Maryland, including the salaries paid.

State: Maryland §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: 19-0003

Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 16-0007 An IIHS provider may bill for a week only if an IIHS activity occurred for the covered youth on at least one day of the billable week. A minimum of one (1) face- to-face contact is required per week. At least fifty percent (50%) of therapist’s contacts with the youth and/or family must be face-to-face. A minimum of fifty percent (50%) of the therapist’s time must be spent working outside the agency and in the youth’s home or community, as documented in the case notes. An individual can only receive IIHS services from one provider at a time. Partial hospitalization/day treatment, mobile crisis response services (MCRS), and other family therapies cannot be charged at the same time. IIHS providers are expected to provide crisis response services for the youth on their caseload. The weekly rate for the IIHS program is based on the cost of a therapist (.5 FTE) and in-home stabilizer (.5 FTE) with a shared caseload of 1:12. An in-home stabilizer provides some of the face-to-face services. The supervisor caseload is a ratio of 1:5. The rate includes other costs, such as rent, communications (phone, internet), and mileage. Payment for Intensive In-Home service as outlined per Attachment 3.1-i page 15-16 and is reimbursed a weekly unit of service. Intensive In-Home providers are defined per Attachment 3.1-i page 16-19. The agency's fee schedule was set as of October 1, 2014 and is effective for services provided on or after that date. All rates are published on the agency's website at https://mmcp.health.maryland.gov/pages/1915(i)-Intensive-Behavioral-Health-Services-for- Children,-Youth-and-Families.aspx State developed fee schedule rates are the same for both governmental and private individual practitioners and the fee schedule and any annual/periodic adjustments to the fee schedule are published at the above website address. EXPRESSIVE AND EXPERIENTIAL BEHAVIORAL SERVICES Proposed Rates Expressive Therapies--Individual, LMHP 45-50 minutes $68.41 Expressive Therapies--Individual, LMHP 75-80 minutes $89.62 Expressive Therapies--Individual, non LMHP 45-50 minutes $62.19 Expressive Therapies--Individual, non LMHP 75-80 minutes $80.85 Expressive Therapies--Group, LMHP 45-60 minutes $24.16 Expressive Therapies--Group, LMHP 75-90 minutes $31.41 Expressive Therapies--Group, non LMHP 45-60 minutes $27.20 Expressive Therapies--Group, non LMHP 75-90 minutes $35.36 LMHP=Licensed Mental Health Practitioner Rates from FY13 PMHS: 45-50 minute rate for an individual clinician in the PMHS, FY 13 62.19 75-80 minute rate for C&A Prolonged Psychotherapy 80.85 45-60 minute rate for C&A group psychotherapy 27.2 Prolonged rate for C&A Group Psychotherapy 35.36 The approved expressive & experiential behavioral therapy providers will bill the Maryland Department of Health directly for the services rendered. No more than

State: Maryland §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: 19-0003

Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 16-0007 one unit of service may be billed for services delivered at the same time by the same staff. Private and public expressive and experiential behavioral therapy providers will be reimbursed at the same rate. Rate development: The following details the rate development for expressive and experiential behavioral therapy services. Expressive and Experiential Behavioral Therapy Services Providers must have a) A bachelor's or master's degree from an accredited college or university; and (b) Current registration in the applicable association. The applicable registrations and associations include the following: x Dance Therapist Registered or Academy of Dance Therapists Registered in The American Dance Therapy Association x Certified by The Equine Assisted Growth and Learning Association (EAGALA)to provide services under the EAGALA model or The North American Handica x Horticultural Therapist Registered by The American Horticultural Therapy Association x Music Therapist-Board Certified by the Board for Music Therapists, Inc in the American Association for Music Therapy, Inc. x Registered Drama Therapist or Board Certified Trainer in the National Association for Drama Therapy These associations, registrations and certifications were identified as having comprehensive standards, continuing education requirements, and examinations. As such, the rate for this service has been aligned with the Medicaid rate for individual practitioners (licensed certified social worker-clinical, nurse psychotherapist, licensed clinical professional counselor, licensed clinical marriage and family therapist, and certified registered nurse practitioner-psychiatric) for 45- 50 minutes of individual therapy with a child or adolescent ($62.19/hour). These rates were set by the State of Maryland at approximately 70% of the Medicare rate for individual therapy provided by practitioners of a similar skill level. Expressive and experiential behavioral therapy service providers who are licensed mental health professionals (licensed certified social worker-clinical, nurse psychotherapist, licensed clinical professional counselor, licensed clinical marriage and family therapist, and certified registered nurse practitioner-psychiatric) are reimbursed for this service at a rate that is 10% greater than the standard rate for non-mental health licensed professionals providing the same service. A differential was selected based on the additional costs to providers to obtain and maintain their license and the cost of and time required to obtain continuing education credits. In the 1915(c) PRTF Demonstration Waiver (RTC Waiver), it was difficult to 1) Ascertain how many of the expressive and experiential behavioral service providers were also licensed mental health clinicians and 2) encourage licensed mental health clinicians who were already Public Mental Health System providers to enroll to provide the additional service (a necessary step in helping families and youth to identify the most appropriate provider to address their needs). As a result, the high rate was developed to address both of these issues through a mechanism to encourage provider enrollment and more accurately track provider utilization. The group rates were set based on

State: Maryland §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: 19-0003

Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 16-0007 the C&A Group Psychotherapy Rates. Payment for Expressive and Experiential Behavioral service as outlined per Attachment 3.1-i page 29-30 and is reimbursed either a 45-50 unit of service or a 75-80 unit of service. Expressive and Experiential Behavioral providers are defined as per Attachment 3.1-i page 27-29. The agency's fee schedule was set as of October 1, 2014 and is effective for service provided on or after that date. All rates are published on the agency's website at https://mmcp.health.maryland.gov/pages/1915(i)-Intensive-Behavioral-Health-Services-for- State developed fee schedule rates are the same for both governmental and private individual practitioners and the fee schedule and any annual/periodic adjustments to the fee schedule are published at the above website address. FAMILY PEER SUPPORT

Personnel Annual Amount or Rate % FT E

Salary Cost Fringe Benefits (25%) Salary + Fringe Cost

Family Support Partner $ 36,000

1

$ 36,000

$ 9,000 $ 45,000.00 Family Support Partner Supervisor $ 58,500

0.10

$ 5,850

$ 1,463 $ 7,312.50 Administrative Assistant $ 35,000

0.25

$ 8,750

$ 2,188 $ 10,937.50 Billing Support Specialist $ 35,000

0.05

$ 1,750

$ 438 $ 2,187.50

Administrator $ 55,000

0.05

$ 2,750

$ 688 $ 3,437.50

Total

1.45

$ 55,100

$ 13,775 $ 68,875.00 Billable Time

Family Support Partner 2080 Total work hours per year (8 hour day * 260 Family Support Partner Supervisor Administrative Assistant 160 Vacation, sick & holiday leave: 20 days@8 Billing Support Specialist 128

Training: 16 days @8hours per day

Administrator 440 Travel (not with client): 10 hours per week Total 728 Total Non-Billable Time 1352 Total Projected Billable Time 0.35 % Non-Billable

State: Maryland §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: 19-0003

Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 16-0007 Other Costs Rent ($15/sq ft, 144 sq ft per FTEs) $ 3,132.00 Cellular Phone, Internet & Communications (@$110/month per FTE)

$ 1,914.00 Mileage (10,500 miles per year @ $0.555/mile) $ 5,827.50 Office supplies & maintenance (printing, copier/fax, etc) @ $750 per FTE

$ 1,088 Management Information System User Fees (@$150/FTE) $ 218 Insurance (generalliability, professional liability) @ $1,000 per FTE

$ 1,450 Indirect Cost (7% of salaries) $ 3,857 Total Cost FTE $ 86,360.50 Hourly rate $ 63.88 30 minute rate $ 31.94 15 minute rate $ 15.97 15 minute telephonic/non-face-to-face rate $ 7.98 Assumptions: *Supervisor: FSP ratio is 1:10

The rate development adheres to the CMS-accepted methodology for cost-based rates, which includes salary, fringe benefits, indirect costs, and transportation costs based on an average of the mileage experience in current peer support programs. Cost estimates conform to our experience with peer support in Maryland.

The 15-minute rate was calculated as the cost for one family support partner for 12 months divided by 1,352 billable service hours. This was based on the amount of time that is spent traveling (without the family present), completing documentation, participating in training (including the Care Coordination Practitioners Certificate Program), and leave time. Indirect costs were calculated at the standard 10% of salaries.

The telephonic rate is established at 50% of the regular rate.

Payment for Family Peer Support service as outlined per Attachment 3.1-i page 26- 27 and is reimbursed a fifteen minute unit of service. Family Peer Support providers are defined per Attachment 3.1-i page 27-29. The agency's fee schedule was set as of October 1, 2014 and is effective for services provided on or after that date. All rates are published on the agency's website at https://mmcp.health.maryland.gov/pages/1915(i)-Intensive-Behavioral-Health-Services-for- Children,-Youth-and-Families.aspx State developed fee schedule rates are the same for both governmental and private individual practitioners and the fee schedule and any annual/periodic adjustments to the fee schedule are published at the above website address.

State: Maryland §1915(i) State plan HCBS State plan Attachment 4.19–B: TN: 19-0003

Effective: October 1, 2019 Approved: June 12, 2019 Supersedes: 16-0007

HCBS Clinic Services (whether or not furnished in a facility for CMI)

Other Services (specify below)

State: Maryland §1915(i) State plan HCBS State plan Attachment 2.2-A: TN: 19-0003 Effective: October 1, 2019 Approved:-XQH

Supersedes: 14-05 Groups Covered Optional Groups other than the Medically Needy In addition to providing State plan HCBS to individuals described in 1915(i)(1), the state may also cover the optional categorically needy eligibility group of individuals described in 1902(a)(10)(A)(ii)(XXII) who are eligible for HCBS under the needs-based criteria established under 1915(i)(1)(A) and have income that does not exceed 150% of the FPL, or who are eligible for HCBS under a waiver approved for the state under Section 1915(c), (d) or (e) or Section 1115 (even if they are not receiving such services), and who do not have income that exceeds 300% of the supplemental security income benefit rate. See 42 CFR § 435.219. (Select one): † No. Does not apply. State does not cover optional categorically needy groups. ; Yes. State covers the following optional categorically needy groups. (Select all that apply): (a) ; Individuals not otherwise eligible for Medicaid who meet the needs-based criteria of the 1915(i) benefit, have income that does not exceed 150% of the federal poverty level, and will receive 1915(i) services. There is no resource test for this group. Methodology used: (Select one): ; SSI. The state uses the following less restrictive 1902(r)(2) income disregards for this group. (Describe, if any): For groups in the state plan home and community-based services group under 42 CFR 42 CFR § 435.219 only, after SSI countable income, the State disregards income in the amount of the difference between 150% of the Federal Poverty Level and 300% of the Federal Poverty Level. † OTHER (describe): (b) † Individuals who are eligible for home and community-based services under a waiver approved for the State under section 1915(c), (d) or (e) (even if they are not receiving such services), and who do not have income that exceeds 300% of the supplemental security income benefit rate. Income limit: (Select one): † 300% of the SSI/FBR † Less than 300% of the SSI/FBR (Specify): _____% Specify the applicable 1915(c), (d), or (e) waiver or waivers for which these individuals would be eligible: (Specify waiver name(s) and number(s)):

State: Maryland §1915(i) State plan HCBS State plan Attachment 2.2-A: TN: 19-0003 Effective: October 1, 2019 Approved:-XQH

Supersedes: 14-05 (c) † Individuals eligible for 1915(c), (d) or (e) -like services under an approved 1115 waiver. The income and resource standards and methodologies are the same as the applicable approved 1115 waiver. Specify the 1115 waiver demonstration or demonstrations for which these individuals would be eligible. (Specify demonstration name(s) and number(s)): 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 114 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.

Table of Contents

State Name: Maryland

State Plan Amendment (SPA)#: 19-0008

This file contains the following documents in the order listed:

1) Approval Letter

2) CMS 179 Form/Summary Form (with 179-like data)

3) Thirteen (13) SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 212M-1850 urs cfNrfß rot MtDrcA¡E & MEDrcAto stwKfs CTÍ{TEN FON AÂEDICAIT' ¡L CHIP SENYICCS X'inancial Management Group October 28,2019 Mr. Dennis Schrader, Director Medicaid Maryland Department of Health 201 W. Preston Street, First Floor Baltimore, MD2l20l RE: State Plan Amendment 19-0008 Dear Mr. Schrader: We have completed our review of State Plan Amendment (SPA) 19-0008. This SPA modifies Attachment 4.19-D of Maryland's Title XIX State Plan. Specifically, this SPA increases nursing facility rates by three percent and updates geographic regions for rate setting purposes. V/e conducted our review of this SPA according to the statutory requirements at sections 1902(a)(3), 1902(a)(13), 1902(a)(30), and 1903(a) of the Social Security Act (the Act) and the regulations at 42 CFR 447 Subpart C. V/e are approving state plan amendment 19-0008 effective July l, 2019. Vy'e are enclosing the CMS-I79 andthe amended plan pages. If you have any questions, or require additional information, please call Gary Knight at (304) 347-5723. Sincerely, Fan Director cc: Lisa Canoll Gary Knight /S/

l)lìP^ftTl\lfNl' Or I ll;^1.'tll ^ND I llllvt^N sliRVtcl:S I ltì^t-1't I ^DI\llNls'lltA lloN TRANSMITTAL AND NOTICI OF APPIIOVAL OF STATE PLAN MATGIIIAI, FOIì: CENTERS FOR MEDICARE & MEDICAID sERvlCnS l()tìñ,t ^PPnovÍ;f) 2. S't'ATll Maryland 3. PROCII^M IDENTIFICA'l'lON: Tl'l'l-ll XIX OF Tt.tu soctAl. sECrJtill'y AC:1' (MUDICAtD) 4. PROPOSED I]FFËCT'IVE DATI: July l,2019 Oet8.0r9J 'l'O: RECIONAI. Al)MlNlS'IRATOR CENI'ERS FOR MEDICARE & MEDICAID SI]RVICES DIìPARTM IìN'T OI; I.I IiA L]'I.I AN D I I UfuI AN SIìRVICIìS 5.'IYpti OF PLAN MA'IDRl^L (L'lrcck Ona) NEW STATE PI.AN ! eV¡:NDrvillNl"to BE CONSTDERED ^S NßW Pt-^N El nurNourNT I. TRANSM I'I-I'AL NUMßßR: I e-0008 6. FEDE¡ìAL STATUTE/RECUI-AI'ION CITA'I'ION: N/A 8. P^GE NUMßER Ot;1'1.il1 t'¡.AN SllC't'tON 0tì Â]'TACI.IMENT: Âtt.4.l9D pg. I (le-0008) Âtt. ,l.l9D pg. ll-9 (le-0008) ^il. 4.191) pg. 10. l6 (19-0008) ^il. 4.19D pg. I I (le-o0os) ^tl.4.19t) pg. 12.13. 15. 17 (19-0008) ¡\rr.1,l9D pg. l4 (r9-ooo8) ^ll. 4.19D pg. lll (le-0008) COMPLETE BLOCKS ó TI.IRU IO IF TI.IIS IS AN AMI]NDMEN'I' Thtnsnittul aoclt 7. FËDERAL BUDGET IMPAC'I': a. IrFY 2019: $5.350 b. FITY 9. PACf] NUMI]I]Iì OF'THß SUPEIISEDÊD P¡.AN SIJCI'ION OR A1'1'^C1-lMLNl' (I[ Åpp\icah|e): ^u.4.19f) pg. I (18-00t0) ^lt.,l.l9D pg. 8-9 (04-10) ^lt. 4.lqD pg. 10. l6 (08-0.i) ^ll..l.l9D pg. ll (13-14) ^11,4. l9f ) pg. l2- 1.1. 15. I 7 (07-01 ) All. .1.l9l) pg. l4 (91-2) ^lt. .1. l9D pg. I tl ( l2-0ll) i\tt. 4. l9l) ps. 20 ( l.:\v 10. SUBJnc'f OF AMENDMHN1': To rcflcct changcs in Statc rcgulations rclatctl to reinrbursenrent for nursing lacility scrviccs. I l. COVIIRNOR'S REVIEW (Checlt Onc): I covrnroR's oFFrcE RDpoR'rED No coMMI]Nr' fl covuaxts oF covERNon's oFFtc¡ì lìNCt-osnD D No Rlìpt.y RßcEtvrD wt'n't¡N 4s DAys o¡r suuMtrt'At, t2. 13.1'YPËD NAME: Dc¡rnis Schrader t4. 1'l'l'l,tl: Mcdicaid Director land ol'l-le¿rhh I5. DATE SUBMITTED: bcr 26, 2019 El on¡rn, ÂS SPECTFTED: Mark A. I.,ccds, Director l-ong'fcrrn Scrviccs & Supports I6. RETURN'TO: Mark A, l.,ecds, Director Long Term Scrvices & Supports - MDI-I 201 W. Prc.ston St.. l*tfìoor Baltinrorc, MD 21201 AL ICE ONL 18. DATE APPROVEDT E COPY ATTACI.IED OFFICIAL: I7. DATE RECEIVED: re. EFFEcnvE DATE OF APltfLV 21. rYPED Neua: çr. PLAN n Dir¿c{o Fu,t à v" 23. REMA FORM r-ICFA -t7e (07 -q2) /S/ /S/

Altacllmcnt 4. l9D Page I STATE PLAN UNDER TÍILD XIX OF TI,IE SOCIAI- SECURII'Y,,t,C'f' Sfâlc olM,rrvlÊnd I'rogram/ScÑic 4.19(d) Nursing lhcility pnynrent mtcs, bnsed on Code of Maryland regularions (COMAR) I 0.09. 10, nccount for thc cosl ol'scrviccs rcquircd to afiûilt or nrnintnin thc higltÈst practicnblc physicnl, rncnlal, and psychosocial rvell-bcing ol'cach rcsidcnr eligiblc l'or Medicaid bcnsfits. Pflyntcnt râtcs lor nursing lhcilìties are based on a prospect¡ve rcitnbursement tncthodology. Påyrncnt râles for nursirrg fncilitics arc bnscd on pricing and are tlrc sunr of per dicnr rcinrbursernent calculnlions in four cost centcrs: adminÍstrativc/routirìe, olhcr pflt¡cnl cnrc, capital, and tursing selviccs (rvhich incluclc certain direct ciìrc costs such ns thcrnpics). PrÕspcctive pâynlcnts n¡c considcled pnid in full. Additional allorvnble ancillnry payments âre listed ân(l nrc paid p¡Òspcctivcly and in fbll. In accordancc rvith the Ornnibus Budget Rcconcilialion Âct ol I987, nursing facility paynrcnt râtcs, elTccl ivc Octobcl I , I 990, líìke into accourìt I hc cosls of nursing lhcilities' conrpliancc rvit lr the fcqu¡rcnìcnts ol'Scctions I9I9(b)(otherthan parngraph (3XF)), I9l9(c),and l9I9(d)ol'the Socifll Scc[rily Act. Aggreg:rte prynrents f'o¡'thesc fhcilities nay not exceed Mcdicare uppel paynrcn( lirnils as spccificrl at 42 CFI\ 44'l .212. Â prov idcr t lrnt rcndcrs cârc lo lvlarylartd M cd ica id rccip¡crìls o l' lcss lhnn I ,000 dnys of calc drrring thc providcr's lìscal¡,eal ntny choosc to Iot bc sulrjcct to cosl rcpoll¡ng rcqUiluncnls and lo âcccpl fls pnyDìcnt thc Mcdicakl st¡rlcwide ¿¡vcr'írgc pírytlÌcnl l'ôr câch day ofcarc. Anv ¡rÌovidcr choosing tlris option is cxcnrpt fronì lhe srrbscquefll nursing cost ccntcÌ wítgc survcy. Nursing fhcilitics thfll Íìrc owned â¡ìd operated by tho Strìlc âre nól paid in accortlanco rvÌth thcsc provisions. 'lhese lacilitics ¡¡'e rcirnbLrrscd reasonatrle cosls basccl upon Mcdicare prirrciplcs of rcasonable cost as described nt 42 CFR 413. Unless othcnvisc dclìncd, indcxing noled uncler the Prospcctivc Reimbursenrcnt Mcthodology rcfbr to thc lalest Skillcd Nùrsing florno without Capitnl Market Baskct Indcx, publislrcd 2 months bcforc the pcriod lbr rvhich rntes are bcing calculatcd, During thc 3,4 pcrccnt pcriod July 1,2019 through June 30, 2020, provirlcr pâynrcnt ratcs shall bc reduccd [ry fronr thc mclhodology dcscribed herein. ]'N,l: 19-0008 Approval Datc: Sunerscdcs 'l'N #: I 8-00010 OcT ? I 2019 lìlïcctive Date: Jr¡ly l. 2019

Attaohnrcnt 4.191) STATE PI"AN UNDER 1]1'LÊ XIX OF'II'IE SOCIAI, SIICUITITY ACT Pagc 8 St¿¡tc lìescrvc l'or l'ulrrrc use TN ll: l9-00011 SupcrscdcS TN #: -!4:-[.0 t]cT 2I 2019 Approval D¿rtc: Effcctivc Dntc: July l. 2019

Attach¡ncnt 4. l9D Page 9 S1'ATI] PI.,AN UNDI]R ]'Il'LE XIX OF'I'TIE SOCIAT, SECURITY ACT State of'Maryland Program/Scn,icc fìcservc f'or fr¡tr¡rc rrsc TN #: 19-0008 Ápprovnl oate: 0CÏ fl S 20fg Supcrscdcs TN /l: 04- l(, Effcctive Date: Julv I, 2019

Altaclurrcut 4.l9D S'fÂl'E PLAN UNDIII'I'I'II.B XIX OII 'I]-IE SOCÍ AT, SI]CI-JIIII'Y ACl' Statc ol'Maryland Page I 0 Progrrrnr/Scnicc Iìeservc for lirtr¡re r¡sc 'lN #: Ì 9-0008 Supurscdes'lll #: 08-03 Approval Date: 0cï ss 20t9 llffbctivc Datc: Jr¡lv 1.2019

Attachmcnt 4. I 9D Page I I Slatc of S1'ATE PLAN UNDEIì'IITLE XIX OI? TI{E SOCIAL SECURITY AC'I Rcservc l'ot fi¡lurc usc TN /l: l9-000f1 Supcrscdes TN //: -!f:Ll Approvul Date : OcT 9E 20îs llffcclivc Date: Jul.v l. 2019

Attachnrcnt 4.191) Page 12 STATE PI.AN UNDEIT TII'LE XIX OIT 1'I.II] SOCIAL SI]CURI'IY A.C'I Str¡tc ol'Maryln¡rd Program/Scrvicc Rcscrvc l'or httulc usc 0cï g E 20t9 Âpproval Datc: __________ 'l'N #: !9¡00Q!l Supcrscdcs'l-N #: Q!Q-l L;fl'cct¡vc Dr¡tÈ: Jul.v l. 2019

Attachnrent 4.1 9D Page 13 S'IA1'I] PLÀN LTNDEII I]TI,E XIX OF'II.IE SOCIAI, SËCURITY ACT State of Maryland Program/Scrvicc Rcsewc for lìlture Llsc TN ll: 19-0008 Approval Oate' [)CT I E 2019 Supqscdcs TN #: Q!01 lìflcct¡vc Date; July l. 20 | 9

Attachnrcnt 4.19D S'I'A'I'E PI,AN UNDER I]'ILE XIX OF TI-IE SOCIAI- SIJCUITII'Y AC Statc of Marvland Pagc 14. Program/Scn,icc ILeservc for fitu¡c usc 'IN #: 19:0008 Superscdcs'l'N #: !!¡Q! 0cT 21 20t9 Approvâl Date: Iìlï'ective Dale: July L 2019

Attachnrsnt 4.19I) Page l5 STATE PLAN UNDER TITLE XIX OF TFIE SOCIAI, SECURITY ACT Statc of Maryland Progrnm/Scrvicc Reserve I'or frtture use TN #: l9-0008 Superscdcs 'IN #: QlQl Approvâl oare:0ÇT S Ê 2.fll$ tifl'cctivc Datc: fulv 1.2019

Attachlncnt 4.19D Pagc I 6 S1'A1'E PLAN UNDI]R'I'IT¡,8 XIX OF"Í'I-IE SOCIÁ,L SIJCUIIIl'Y ACT Statc ol'Maryland Program/Scrvicc Iìcscrvc for futurc use 1'N ,lr 19-0008 Supcrsedcs'ì-N #: 08-03 0cT 2 s 20î$ Âpploval Datc: lìfl'cctivc Datc: July l. 2019

Attachnren( 4. l9D Page 17 STATE PLAN UNDEII'II]'I,E XIX OF TI.IE SOCIAL SIiCURII'Y ACT Stâtc ol'Maryland Progrnm/Scwicc Rcscrvc l'or ltrturc usc Sr¡puscdcs TN #: QZO!

Altachmcnt 4. l9l) Pagc 18 S'TATE PI.AN I.JNDER'TIl'LI] XtX OF'II-IE SOCIAL SECUI(I1'Y AC]' Statc of Maryl¿rnd , Program/Scrvicc Anncn4ix A cOiq4\ß t0.09.10.30 .30 Roimburscme ¡tt Chsscs. A. Thc reinlburscntc¡tt classcs l'or the Administrative ¿¡nd flot¡tine cost ccntcr ÂÍc as lbllorvs: (l) Facilities iu the Baltitìtors mctropolitan tcgion consisting ol'thc following couttties: (a) Annc Arundcl, (b) llaltimorc, (c) Carroll, (d) l'larford, and (e) I-lowald; (l-l) Facilitics irr llaltinrorc City; (2) Facilities in the Washington rcgion consisting of'thc follorving counties: (a) Charles, (b) Morltgonrery, ând (c) Princc Gcorgc's; (3) l:'acilitics ilì thc nonrìctropolitan regiou consisting ofthe lollowing corrnties Allcgany, Calvsrt, Carolinc, Cecil, Dorchester', Frcderick, Gflrrett, Kent, Quccn Atrne's, St. Mâry's, Soulersel, (l) 1-albol, (nr) Washington, (n) Wiconrico. and (o) Worcester. (a) (b) (c) (d) (e) (Ð (e) (h) (i) c) (k) 'lN fl: 19-0008 Supcrscdes TN #: l2-08 Approval Datc: CIcT 2 E 20t9 Efïcctive Date: Julv I . 2019

Attachment 4,19D Page 20 S1'A'1'E PI,AN IjNDER TITLI] XIX OII TI-IE SOCIAL SIICURII'Y AC'I State ol'Maryland Progrnm/Scrvicc D. Efïcctive July l, 2020, lhc rcimbursenìent classcs ftrr the Nursing Service cost ccrì(cr are as follows: (l) Facilities in the Baltirnorc Metro rcgion cousisting ol'llaltinrore City and thc f'ollowing counties: (a) Ànne Arundcl; (b) Bnltinorc; (c) Cnrroll; (cl) Cccil; (e) l"larl'ord; and (f) Ilolard; (2) Facilitics irr thc Washington Metro region consisting of the f'ollorving countics: (a) Calvcrtl (b) Charlcs; (c) Frederick; (d) Montgomcry; (e) Priuce George's; aud (l) St. Mary's; (3) Facilitics in thc lìaslern region consisting of thc following counties: (a) Ca¡'olincl (b) Dorchesler; (c) Kcnt; (d) Quecn Annc's; (c) Somcrsct; (f)'l'albot; (g) Wiconrico; and (h) Worccstcr; ând (4) Facilitics in the Westenr region consisting of'thc l'ollorving countics: (a) Allcgany; (b) Gar¡ctl; and (c) Washington. lì. During thc pcriod July 1,2019 through June 30,2020, reimbursçnrcnt f'or thc Nursing Scrvicc cost c0nter shall be thc sun of 50 percenl of thc amount calculatcd in accordance with the rcimburscmcnt classcs undcr $C ol'this regulntion and 50 pcrccnt of'the ânrount calculated in accordancc with the reimbursenrent classes under $D of'this regulation, 'l'N #: l9-0008 Supcrscdcs 'l'N f/: NIU ^ppfovnt Dârc: [)cT 2 E 20|9 Effcctivc DÍìre : J_nly_L20l_g

Table of Contents

State/Territory Name: Maryland State Plan Amendment (SPA) #: 19-0009 This file contains the following documents in the order listed: 1) Package Information 2) Approval Letter 3) Approved SPA Pages

Records / Submission Packages MD - Submission Package - MD2019MS0002O - (MD-19-0009) - Health Homes CMS-10434 OMB 0938-1188 Package Information Package ID MD2019MS0002O Program Name Migrated_HH.MD HHS SPA ID MD-19-0009 Version Number 1 Submitted By Katia Fortune Package Disposition Priority Code P2 Submission Type OŰcial State MD Region Philadelphia, PA Package Status Approved Submission Date 9/27/2019 Approval Date 10/29/2019 3:56 PM EDT Summary Reviewable Units Versions Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Philadelphia Regional OŰce 150 S. Independence Mall West, Suite 216, The Public Ledger Building Philadelphia, PA 9106-34991 Division of Medicaid and Children's Health Operations October 29, 2019 Mr. Dennis Schrader Medicaid Director Maryland Department of Health 201 West Preston Street Baltimore, MD 21201 Re: Approval of State Plan Amendment MD-19-0009 Migrated_HH.MD HHS Dear Mr. Dennis Schrader : On September 27, 2019, the Centers for Medicare and Medicaid Services (CMS) received Maryland State Plan Amendment (SPA) MD-19-0009 for Migrated_HH.MD HHS to This amendment increases the rates for the Behavioral Health, Health Home program, by 3.5 percent, for dates of service beginning July 1, 2019. We approve Maryland State Plan Amendment (SPA) MD-19-0009 on October 29, 2019 with an eſective date(s) of July 01, 2019. Name Date Created No items available If you have any questions regarding this amendment, please contact Talbatha Myatt at talbatha.myatt@cms.hhs.gov. Sincerely, Francis T. McCullough Director Division of Medicaid Field Operations East Regional Operations Group Division of Medicaid and Children's Health Operations Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MD2019MS0002O | MD-19-0009 | Migrated_HH.MD HHS Package Header Package ID MD2019MS0002O Submission Type OŰcial Approval Date 10/29/2019 Superseded SPA ID MD-18-0008 System-Derived SPA ID MD-19-0009 Initial Submission Date 9/27/2019 Eſective Date 7/1/2019 Payment Methodology The State's Health Homes payment methodology will contain the following features Fee for Service Individual Rates Per Service Fee for Service Rates based on Severity of each individual's chronic conditions Capabilities of the team of health care professionals, designated provider, or health team Other

Describe below Health Homes may receive a one-time reimbursement for the completion of each participants’ initial intake and assessment necessary for enrollment into the Health Home. The payment will be the same as the rate paid for monthly services on a per-member basis. The monthly rate is contingent upon the Health Home meeting the requirements set forth in the Health Home applications, as determined by the State of Maryland, including the provision of a minimum of two services in the month. The Health Homes are not paying any monies to other providers. There is only one exchange of payment and that is from the State to the Health Home providers. Health Home providers must document services and outcomes within the participant's ţle and in eMedicaid. These documents are accessible to the Department and the Department's designees through eMedicaid and are auditable. Rates are reviewed annually. Health Home participants may only be enrolled in one Health Home at a time. If participant is enrolled in a Health Home, Maryland's system automatically blocks the participant from being enrolled in another Health Home.

Health Homes will be paid a monthly rate based on the employment costs of required Health Home staſ, using salary and additional employment cost estimates for each of the required positions and their respective ratios. Payment is contingent upon the Health Home meeting the requirements set forth in the Health Home applications, as determined by the State of Maryland. Failure to meet such requirements is ground for payment sanctions or revocation of Health Home status. The Department does not pay for separate billing for services which are included as part of another service. At the end of each month, Health Homes will ensure that all Health Home services and outcomes have been reported into eMedicaid. The provider will then submit a bill within 30 days for all participants that received the minimum Health Home service requirement in the preceding month. The provider may begin billing for a Health Home participant when the intake portion of that individual’s eMedicaid ţle has been completed with the necessary demographics, qualifying diagnoses baseline data, and consent form. The initial intake process itself qualiţes as a Health Home service. The ongoing criteria for receiving a monthly payment is: 1. The individual is identiţed in the State’s Medicaid Management Information System (MMIS) as Medicaid-eligible and authorized to receive PRP, MT, or OTP services; 2. The individual was enrolled as a Health Home member with the Health Home provider in the month for which the provider is submitting a

bill for Health Home services; and 3. The individual has received a minimum of two Health Home services in the previous month, which are documented in the eMedicaid system. The agency's fee schedule (rate) was last updated on July 1, 2019 and is eſective for services provided on or after that date. Eſective July 1, 2019, the Health Home rate will be $110.19. Describe any variations in payment based on provider qualiţcations, individual care needs, or the intensity of the services provided There are no variations in payment. Per Member, Per Month Rates Comprehensive Methodology Included in the Plan Incentive Payment Reimbursement PCCM (description included in Service Delivery section) Risk Based Managed Care (description included in Service Delivery section) Alternative models of payment, other than Fee for Service or PMPM payments (describe below)

Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MD2019MS0002O | MD-19-0009 | Migrated_HH.MD HHS Package Header Package ID MD2019MS0002O Submission Type OŰcial Approval Date 10/29/2019 Superseded SPA ID MD-18-0008 System-Derived SPA ID MD-19-0009 Initial Submission Date 9/27/2019 Eſective Date 7/1/2019 Agency Rates Describe the rates used Eſective Date 7/1/2019 Website where rates are displayed health.maryland.gov/providerinfo FFS Rates included in plan Comprehensive methodology included in plan The agency rates are set as of the following date and are eſective for services provided on or after that date

Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MD2019MS0002O | MD-19-0009 | Migrated_HH.MD HHS Package Header Package ID MD2019MS0002O Submission Type OŰcial Approval Date 10/29/2019 Superseded SPA ID MD-18-0008 System-Derived SPA ID MD-19-0009 Initial Submission Date 9/27/2019 Eſective Date 7/1/2019 Rate Development Provide a comprehensive description in the SPA of the manner in which rates were set 1. In the SPA please provide the cost data and assumptions that were used to develop each of the rates 2. Please identify the reimbursable unit(s) of service 3. Please describe the minimum level of activities that the state agency requires for providers to receive payment per the deţned unit 4. Please describe the state's standards and process required for service documentation, and 5. Please describe in the SPA the procedures for reviewing and rebasing the rates, including the frequency with which the state will review the rates, and the factors that will be reviewed by the state in order to understand if the rates are economic and eŰcient and suŰcient to ensure quality services. Comprehensive Description Behavioral Health rates are typically reviewed and updated for inŤation annually. This program was added to that annual review process in FY 2017. Eſective July 1, 2016 the Health Home rate will be increased 2% bringing the rate to $100.85. This change is being submitted to CMS through a separate process, with public notice being published June 10th. MD then increased the rateby 2%, eſective July 1, 2017 and by 3.5% in 2018 and 2019. There is no tiered payment for this service. All Health Homes receive the same monthly rate if they perform the minimum number of services for that individual.

Health Homes Payment Methodologies MEDICAID | Medicaid State Plan | Health Homes | MD2019MS0002O | MD-19-0009 | Migrated_HH.MD HHS Package Header Package ID MD2019MS0002O Submission Type OŰcial Approval Date 10/29/2019 Superseded SPA ID MD-18-0008 System-Derived SPA ID MD-19-0009 Initial Submission Date 9/27/2019 Eſective Date 7/1/2019 Assurances Describe below how non- duplication of payment will be achieved Recipients of speciţed waiver services and mental health case management that may be duplicative of Health Home services will not be eligible to enroll in a Health Home. In addition to oſering guidance to providers regarding this restriction, the State may periodically examine recipient ţles to ensure that Health Home participants are not receiving similar services through other Medicaid-funded programs. Optional Supporting Material Upload Name Date Created No items available The State provides assurance that it will ensure non-duplication of payment for services similar to Health Homes services that are oſered/covered under a diſerent statutory authority, such as 1915(c) waivers or targeted case management. The state has developed payment methodologies and rates that are consistent with section 1902(a)(30)(A). The State provides assurance that all governmental and private providers are reimbursed according to the same rate schedule, unless otherwise described above. The State provides assurance that it shall reimburse providers directly, except when there are employment or contractual arrangements consistent with section 1902(a)(32).

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 OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 10/30/2019 7:13 AM EDT

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY__________________ $ __________________ b. FFY__________________ $ __________________ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. S FICIAL 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED 16. RETURN TO FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. TE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21. TYPED NAME 22. TITLE 23. REMARKS EFFECTIVE DA FORM CMS-179 (07/92) Instructions on Back 5IF
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       PED NAME 5SJDJB 3PEEZ   $QQH0DULH&RVWHOOR &0&6'HSXW\'LUHFWRU  Anne M. Costello - S Digitally signed by Anne M. Costello -S Date: 2020.04.17 09:05:15 -04'00'

State/Territory: Maryland NEW Supersedes TN: Effective Date:DĂƌĐŚϭ͕ϮϬϮϬ 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: 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). TN: 20-0001 Approval Date: Describe shorter period here. N/A Section 7.4 page 90 Ɖƌŝůϭϳ͕ϮϬϮϬ

State/Territory: Maryland Supersedes TN: NEW Effective Date:DĂƌĐŚϭ͕ϮϬϮϬ c. Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in [insert name of state] Medicaid state plan, as described below: 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. 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. Less restrictive income methodologies: TN: 20-0001 Approval Date: Please describe the modifications to the timeline. Include name of the optional eligibility group and applicable income and resource standard. Section 7.4 page 91 Ɖƌŝůϭϳ͕ϮϬϮϬ

State/Territory: Maryland TN: 20-0001 Approval Date: Supersedes TN: NEW Effective Date:DĂƌĐŚϭ͕ϮϬϮϬ 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 inconsistencies 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. 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. 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 the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. Please describe any limitations related to the populations included or the number of allowable PE periods. Section 7.4 page 92 Ɖƌŝůϭϳ͕ϮϬϮϬ

State/Territory: Maryland TN: 20-0001 Approval Date: Supersedes TN: NEW Effective Date:DĂƌĐŚϭ͕ϮϬϮϬ 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. 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 the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 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). The State waives cost-sharing for testing services (including in vitro diagnostic products), testing-related services, and treatments for COVID-19, including vaccines, specialized equipment and therapies, for any quarter in which the temporary increased FMAP is claimed. Section 7.4 page 93 Ɖƌŝůϭϳ͕ϮϬϮϬ

State/Territory: Maryland TN: 20-0001 Approval Date: Supersedes TN: NEW Effective Date:DĂƌĐŚϭ͕ϮϬϮϬ 2. _X_ The agency suspends enrollment fees, premiums and similar charges for: a. All beneficiaries b. X The following eligibility groups or categorical population 3. _ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Section D – Benefits Benefits: 1. The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. _ The agency makes the following adjustments to benefits currently covered in the state plan: 3. The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at Please list the applicable eligibility groups or populations. §1902(a)(10)(A)(ii)(XV) TWWIIA Basic group and §1902(a)(10)(A)(ii)(XIV) targeted low-income children. These are the only groups in the state plan to which a premium applies. Section 7.4 page 94 Ɖƌŝůϭϳ͕ϮϬϮϬ

State/Territory: Maryland TN: 20-0001 Approval Date: Supersedes TN: NEW Effective Date:DĂƌĐŚϭ͕ϮϬϮϬ 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). a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Telehealth: 5. The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: 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. 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. Please describe. Please describe the change in days or quantities that are allowed for the emergency period and for which drugs. Please describe the manner in which professional dispensing fees are adjusted. Section 7.4 page 95 Ɖƌŝůϭϳ͕ϮϬϮϬ

State/Territory: Maryland TN: 20-0001 Approval Date: Supersedes TN: NEW Effective Date:DĂƌĐŚϭ͕ϮϬϮϬ 9. The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. Newly added benefits described in Section D are paid using the following methodology: a. Published fee schedules – Effective date (enter date of change): Location (list published location): b. Other: Increases to state plan payment methodologies: 2. The agency increases payment rates for the following services: a. Payment increases are targeted based on the following criteria: b. Payments are increased through: i. A supplemental payment or add-on within applicable upper payment limits: ii. An increase to rates as described below. Describe methodology here. Please list all that apply. Please describe criteria. Please describe. Section 7.4 page 96 Ɖƌŝůϭϳ͕ϮϬϮϬ

State/Territory: Maryland TN: 20-0001 Approval Date: Supersedes TN: NEW Effective Date:DĂƌĐŚϭ͕ϮϬϮϬ Rates are increased: 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: Payment for services delivered via telehealth: 3. For the duration of the emergency, the state authorizes payments for telehealth services that: a. Are not otherwise paid under the Medicaid state plan; b. Differ from payments for the same services when provided face to face; c. Differ from current state plan provisions governing reimbursement for telehealth; d. Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Please describe. Describe telehealth payment variation. Section 7.4 page 97 Ɖƌŝůϭϳ͕ϮϬϮϬ

State/Territory: Maryland TN: 20-0001 Approval Date: Supersedes TN: NEW Effective Date:DĂƌĐŚϭ͕ϮϬϮϬ Other: 4. Other payment changes: Section F – Post-Eligibility Treatment of Income 1. The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. The individual’s total income b. 300 percent of the SSI federal benefit rate c. Other reasonable amount: 2. The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information Please describe. Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section 7.4 page 98 Ɖƌŝůϭϳ͕ϮϬϮϬ

State/Territory: Maryland TN: 20-0001 Approval Date: Supersedes TN: NEW Effective Date:DĂƌĐŚϭ͕ϮϬϮϬ 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. Section 7.4 page 99 Ɖƌŝůϭϳ͕ϮϬϮϬ

Table of Contents State/Territory Name: Maryland State Plan Amendment (SPA) #: 20-0002 This file contains the following documents in the order listed: 1) Package Information 2) Approval Letter 3) Submission Summary 4) Approved SPA Pages

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Table of Contents State/Territory Name: Maryland

State Plan Amendment (SPA) #: 20-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601 Financial Management Group Dennis R, Schrader Medicaid Director Maryland Department of Health 201 W. Preston St., 5th Floor Baltimore, MD 21201 RE: Maryland State Plan Amendment (SPA) Transmittal Number 20-0010 Dear Mr. Schrader: We have reviewed the proposed amendment to Attachment 4.19-B of Maryland's state plan, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on October 22, 2020. This plan amendment creates a public Emergency Service Transporter Supplemental Payment Program (ESPP) for public emergency service transportation providers. Based upon the information provided by the State, we are approving the amendment with an effective date of October 1, 2020. We are enclosing the approved CMS-179 and a copy of the new state plan pages. If you have any additional questions or need further assistance, please contact Gary Knight at 304.347.5723 or Gary.Knight@cms.hhs.gov. Sincerely, Todd McMillion Director Division of Reimbursement Review Enclosures March 16, 2021

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2. STATE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY__________________ $ __________________ b. FFY__________________ $ __________________ 8. 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 10. SUBJECT OF AMENDMENT 11. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL 13. TYPED NAME 14. TITLE 15. DATE SUBMITTED 16. RETURN TO FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED 18. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 19. TE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21. TYPED NAME 22. TITLE 23. REMARKS EFFECTIVE DA FORM CMS-179 (07/92) Instructions on Back 2 0 X October 1, 2020 MD PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Att. 4.19B pg. 40A-40E (20-0010) Att. 4.19B pg. 40A-40E (NEW) 2021

60,000 2022

80,000 X Dennis R. Schrader Medicaid Director Maryland Department of Health 201 W. Preston St., 5th Floor Baltimore, MD 21201 Assistant Medicaid Director Tricia Roddy The purpose of this amendment is to create a public Emergency Service Transporter Supplemental Payment Program (ESPP) for public emergency service transportation providers. N/A 0 0 1 0 10/22/2020 10/1/2020 Todd McMillion 3/16/2021 Director, FMG Division of Reimbursement Review October 22, 2020 42 CFR 431.53 3/10/2021: Maryland agreed to P&I adding 42 CFR 431.53 in Block 6

State of Maryland Attachment 4.19-B Page 40-A TN No. 20-0010 Approval Date _________________ Supersedes TN No. NEW Effective Date October 1, 2020 3. Emergency Service Transporter Supplemental Payment Program (ESPP). (a) Reimbursement rates for Emergency Service Transporters are outlined in Attachment 4.19- B, page 40. (b) SUPPLEMENTAL PAYMENT FOR JURISDICTIONAL EMERGENCY MEDICAL SERVICES OPERATIONAL PROGRAMS Effective October 1, 2020, Jurisdictional Emergency Medical Services Operational Programs (JEMSOPs) that meet the specified requirements outlined in Section 3(c) below and provide ground emergency transportation services to Medicaid recipients as defined in Attachment 3.1A page 30, will be eligible for a supplemental payment. This supplemental payment applies to Emergency Transportation Services (ETS) rendered to Medicaid recipients by eligible JEMSOPs on or after October 1, 2020. EPSS is a voluntary program, and JEMSOPs are not required to participate. Supplemental payments provided by this program are available only for allowable costs that are in excess of Medicaid reimbursement rates paid to Emergency Service Transporters in accordance with Attachment 4.19-B, page 40 that eligible entities receive for ETS services rendered to eligible Medicaid recipients. Total reimbursements under the ESPP program are capped (including supplemental payments) at one hundred percent of actual costs. The Maryland Department of Health (the Department) will recognize a supplemental payment equal to the total allowable Medicaid costs of eligible JEMSOPs for providing services as set forth below. (c) To qualify for supplemental payments, providers must meet all of the following: 1. Be enrolled as a Medicaid provider for the period being claimed on their annual cost report; 2. Provide ground Emergency Transport Services to Medicaid recipients; and 3. Be a “Jurisdictional Emergency Medical Services Operational Program," which is defined under COMAR 30.03.02 as: “an institution, agency, corporation, or other entity that has been approved by the Emergency Medical Service Board to provide oversight for each of the local government and State and federal emergency medical services programs.” Providers meeting all of these qualifications will be considered “Eligible Providers.” (d) Supplemental Reimbursement Methodology – General Provisions 3/16/21

State of Maryland Attachment 4.19-B Page 40-B TN No. 20-0010 Approval Date _________________ Supersedes TN No. NEW Effective Date October 1, 2020 1. Computation of allowable costs and their allocation methodology must be determined in accordance with the Centers for Medicare and Medicaid Services (CMS) Provider Reimbursement Manual (CMS Pub. 15-1), CMS non-institutional reimbursement policies, Medicare cost reimbursement principles in 42 Code of Federal Regulations (CFR), Part 413 and Section 1861 of the Federal Social Security Act (42 USC, Section 1395x), and 2 C.F.R. Part 200 as implemented by HHS at 45 C.F.R., part 75, which establish principles and standards for determining allowable costs and the methodology for allocation and apportioning those expenses to the Medicaid program, except as expressly modified below. 2. The total uncompensated care costs of each Eligible Provider available to be reimbursed under this supplemental reimbursement program will equal the shortfall resulting from the allowable costs determined using the Cost Determination Protocols for each Eligible Provider providing ETS to Maryland Medicaid recipients, net of the amounts received and payable from the Maryland Medicaid program and all other sources of reimbursement for such services provided to Maryland Medicaid recipients. If the Eligible Providers do not have any uncompensated care costs, then the provider will not receive a supplemental payment under this supplemental reimbursement program. (e) Cost Determination Protocols 1. An Eligible Provider’s specific allowable cost per-ETS transport rate will be calculated based on the provider’s financial data reported on the state-approved cost report. The per-ETS transport cost rate will be the sum of actual allowable direct and indirect costs of providing ETS divided by the actual number of emergency transports provided for the applicable service period. 2. Direct costs for providing ETS include only the unallocated payroll costs for the shifts in which personnel dedicate 100 percent of their time to providing medical transport services ETS, medical equipment and supplies, and other costs directly related to the delivery of covered services, such as first-line supervision, materials and supplies, professional and contracted services, capital outlay, travel, and training. These costs must be in compliance with Medicaid non-institutional reimbursement policy and are directly attributable to the provision of the ETS. 3. The total percentage of time spent on ETS calls throughout the cost reporting period will be calculated using Computer Aided Dispatch (CAD)/trip allocation statistics and used as an allocation methodology for those costs “shared” between ETS vs. Non-ETS 3/16/21

State of Maryland Attachment 4.19-B Page 40-C TN No. 20-0010 Approval Date _________________ Supersedes TN No. NEW Effective Date October 1, 2020 divisions. Eligible Providers will allocate shared Capital Related and Salaries & Benefits (CRSB) costs based on CAD/trip allocation statistics. 4. Indirect costs are determined in accordance to one of the following options. a. Eligible Providers receiving more than $35 million in direct federal funding in a calendar year must either have a Cost Allocation Plan (CAP) or a cognizant department approved indirect rate agreement in place with its federal cognizant department to identify indirect cost. If the Eligible Provider does not have a CAP or an indirect rate agreement in place with its federal cognizant department and it would like to claim indirect cost in association with a non-institutional service, it must obtain one or the other before it can claim any indirect cost. b. Eligible Providers receiving less than $35 million of direct federal funding in a calendar year are required to develop and maintain an indirect rate proposal for purposes of audit. In the absence of an indirect rate proposal, Eligible Providers may use methods originating from a CAP to identify its indirect cost. If the Eligible Provider does not have an indirect rate proposal on file or a CAP in place and it would like to claim indirect cost in association with a non- institutional service, it must secure one or the other before it can claim any indirect cost. c. Eligible Providers receiving no direct federal funding can use any of the following previously established methodologies to identify indirect cost: i. A CAP with its local/municipal government ii. An indirect rate negotiated with its local government iii. Direct identification through use of a cost report d. If the Eligible Provider never established any of the above methodologies, it may do so, or it may elect to use the 10% de minimis rate to identify its indirect cost. (f) Cost Settlement Process 1. The payments and the number of ETS transports reported in the as-filed cost report will be reconciled with the Department’s Medicaid Management Information System (MMIS) reports generated for the cost reporting period within 12 months of the as-filed cost report deadline. The Department will make adjustments to the as-filed cost report based on the reconciliation results of the most recently retrieved MMIS report. 3/16/21

State of Maryland Attachment 4.19-B Page 40-D TN No. 20-0010 Approval Date _________________ Supersedes TN No. NEW Effective Date October 1, 2020 2. Each Eligible Provider will receive an annual lump sum payment in an amount equal to the total of the uncompensated care costs as defined in the above Supplemental Reimbursement Methodology – General Provisions Section 3(d)(2). 3. The Department will perform a final reconciliation where it will settle the Eligible Provider’s annual cost report as reviewed and/or audited within the following calendar year. The Department will compute the net ETS allowable costs using reviewed and/or audited per-ETS cost, and the number of fee-for-service ETS transports reflected in the updated MMIS reports. Actual net allowable costs will be compared to the total Medicaid reimbursement paid to the provider for eligible services, including claims payments, third party liability, copayments, spenddown, settlement payments made, and any other source of reimbursement received by the Eligible Provider for the period. If, at the end of the final reconciliation, it is determined that the Eligible Provider has been overpaid, the provider will return the overpayment to the Department and the Department will return the overpayment to the federal government pursuant to 42 CFR 433.316. If an underpayment is determined, then the Eligible Provider will receive a final supplemental payment in the amount of the underpayment. (g) Eligible Provider Reporting Requirements 1. Cost reports are due no later than 180 days after the last day of the State Fiscal Year. A request for an extension shall only be approved when a provider’s operations are significantly and/or adversely affected due to extraordinary circumstances, which the provider has no control, such as, flood or fire. The written request must include a detailed explanation of the circumstances supporting the need for additional time and be postmarked within the 180 days after the last day of the applicable State Fiscal Year. Filing extensions may be granted by the Department for good cause, but such extensions are made at the discretion of the Department. 2. Only cost reports from Eligible Providers as defined in Section 3(c) will be accepted. 3. Participating Eligible Providers who meet the required state enrollment criteria are eligible for federal reimbursement up to reconciled cost in accordance with 3(c) through 3(f) for services provided on or after October 1, 2020. a. Eligible Providers will be paid interim rates equal to the Medicaid reimbursement rates paid to other ETS providers in accordance with Attachment 4.19-B, page 40. The interim rates are provisional in nature, pending the submission of an annual cost report and the completion of cost reconciliation and a cost settlement for that period. Settlements are a separate 3/16/21

State of Maryland Attachment 4.19-B Page 40-E TN No. 20-0010 Approval Date _________________ Supersedes TN No. NEW Effective Date October 1, 2020 transaction, occurring as an adjustment to prior year costs and are not to be used to offset future rates. b. Eligible Providers will submit a state approved cost report annually, on a form approved by the Department. c. “Allowable costs” will be determined in accordance with the CMS Provider Reimbursement Manual (CMS Pub. 15-1), CMS non-institutional reimbursement policies, Medicare cost reimbursement principles in 42 Code of Federal Regulations (CFR), Part 413 and Section 1861 of the Federal Social Security Act (42 USC, Section 1395x), and 2 CFR, part 200 as implemented by HHS at 45 CFR, part 75. i. “Direct costs” are those costs that are identified by 45 CFR 75.413 that: 1. Can be identified specifically with a particular final cost objective (to meet emergency transportation service requirements), such as a federal award, or other internally or externally funded activity; or 2. Can be directly assigned to such activities relatively easily with a high degree of accuracy. ii. “Indirect costs” means the costs that cannot be readily assigned to a particular cost objective and are those that have been incurred for common or joint purposes. d. Eligible Provider's reported direct and indirect costs are allocated to the Medicaid program by applying a Medicaid utilization statistic ratio, to Medicaid transports associated with paid claims for the dates of service covered by the submitted cost report. 3/16/21

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group 6HSWHPEHU, 2021 Tricia Roddy Medicaid Director Maryland Department of Health 201 West Preston Street Baltimore, MD, 21201 Re: Maryland State Plan Amendment (SPA) MD-21-0006 Dear Ms. Roddy: The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) MD-21-0006. This amendment proposes to add medication-assisted treatment (MAT) as a mandatory benefit in the Medicaid state plan. This letter is to inform you that Maryland’s Medicaid SPA Transmittal Number MD-21-0006 ZDVapproved RQ$XJXVWeffective October 1, 2020 until September 30, 2025, pursuant to1905(a)(29) of the Social Security Act and Section 1006(b) of the SUPPORT Act. Section 1006(b) of the SUPPORT for Patients and Communities Act (SUPPORT Act), signed into law on October 24, 2018, amended section 1902(a)(10)(A) of the Act to require state Medicaid plans to include coverage of MAT for all eligible to enroll in the state plan or waiver of state plan. Section 1006(b) also added a new paragraph 1905(a)(29) to the Act to include the new required benefit in the definition of “medical assistance” and to specify that the new required benefit will be in effect for the period beginning October 1, 2020, and ending September 30, 2025. Section 1006(b) of the SUPPORT Act also added section 1905(ee)(1) to the Act to define MAT, for purposes of the new required coverage, as: . . . all drugs approved under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355), including methadone, and all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262) to treat opioid use disorders; and[,] . . . with respect to the provision of such drugs and biological products, counseling services and behavioral therapy. Pursuant to section 1135(b)(5) and 1135(b)(1)(C) of the Act, due to the COVID-19 public health emergency (PHE), CMS issued an approval letter on February 26, 2021 allowing Maryland to modify the SPA submission requirements at 42 C.F.R. 430.20, to allow the state to submit a SPA implementing section 1905(a)(29) of the Act by March 31, 2021 that would take effect on October 1, 2020.

Page 2 – Ms. Roddy Pursuant to section 1135(b)(5) and 1135(b)(1)(C) of the Act, due to the COVID-19 PHE, CMS issued an approval letter on March 26, 2020 allowing Maryland to modify the public notice time frames set forth at 42 C.F.R. 447.205, in order to obtain an effective date of October 1, 2020 for its SPA implementing statewide methods and standards for setting payment rates for the benefit described at section 1905(a)(29) of the Act. The state issued public notice on February 10, 2021. CMS conducted our review of your submittal according to statutory requirements in Title XIX of the Act and implementing regulations. If you have any questions, please contact Talbatha Myatt at 215-861-4259 or via email at Talbatha.Myatt@cms.hhs.gov. Sincerely, James G. Scott, Director Division of Program Operations cc: Alison Donley, State Plan Coordinator Nina McHugh, Medicaid Provider Services Administration

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TN No.: 21-0006 Approval Date:_____________ Effective Date: October 1, 2020 Supercedes TN No.: 16-0010 Attachment 3.1-A Page 29C-21 STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND 13.Other diagnostic, screening, preventive, and rehabilitation services, i.e., other than those provided elsewhere in the plan. d. Rehabilitative Services V. Community-Based Substance Use Disorder Services Community-based substance use disorder services are provided in non-hospital community-based settings. From October 1, 2020 through September 30, 2025, medication assisted treatment (MAT) to treat opioid use disorder (OUD) as defined at section 1905(ee)(1) of the Social Security Act is covered exclusively in Supplement to Attachment 3.1-A for 1905(a)(29). Covered Services: A. Comprehensive substance use disorder assessment: (1) Definition of Service: A comprehensive substance use disorder assessment is a process of determining a participant’s current health status and relevant history in areas including substance use, mental health, social supports, and somatic health. Providers use a comprehensive assessment to establish the type and intensity of services participants will need to adequately address their substance use disorder. (2) Service Requirements: Comprehensive substance use disorder assessment at a minimum shall be reviewed and approved by a licensed physician or licensed practitioner of the healing arts, within the scope of his or her practice under State law, and shall include an assessment of drug and alcohol use, as well as substance use disorder treatment history. It shall also include referrals for physical and mental health services; and a recommendation for the appropriate level of substance use disorder treatment. B. Group and individual substance use disorder counseling services (1) Definition of Service: Individual and group counseling sessions involve evidence- based psychotherapeutic interventions. Cognitive- behavioral, motivational, and insight- based techniques are used according to each participant’s needs. The therapeutic style is client-centered and flexible. Treatment usually involves a combination of individual and group counseling. The primary goals of treatment are to: 

TN No.: 21-0006 Approval Date:_____________ Effective Date: October 1, 2020 Supercedes TN No.: 16-0010 Attachment 3.1-A Page 29C-22 STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND x Develop skills to enable individuals to abstain from all non-prescribed psychoactive substances; x Develop relapse prevention strategies through family and/or other support networks; and x Engage participants in long-term recovery strategies. (2) Service Requirements: Before providing services described in this section, the provider shall develop a written individualized treatment plan, in conjunction with the participant based on the comprehensive assessment. This plan which shall be updated as clinically appropriate, shall be reviewed and approved by a licensed physician or licensed practitioner of the healing arts within the scope of his or her practice under State law, and shall include: x An assessment of the participant’s individual needs; and x The participant’s treatment plan goals. C. Intensive Outpatient Services (1) Definition of Service: Intensive Outpatient service is a more intense form of treatment than group and individual counseling. This service is either a step-down treatment from more intensive, often inpatient-based care or a step-up when a participant is in need of more intensive services. While less intensive than inpatient care, it provides a substantial range of treatment intensity and bridges the gap between medically managed or medically monitored intensive inpatient treatment and traditional outpatient services of low intensity. Participants participate within an ambulatory therapeutic setting while residing in a separate location. (2) Service Requirements: Before providing Intensive Outpatient Services as described in this section, the provider must develop a written individualized treatment plan, in conjunction with the participant based on the comprehensive assessment. This plan shall be updated as clinically appropriate, shall be reviewed and approved by a licensed physician or licensed practitioner of the healing arts, within the scope of his or her practice under State law. The individualized treatment plan shall include the following requirements: x An assessment of the participant’s individual needs; and x The participant’s treatment plan goals; and x Specific interventions for meeting the treatment plan goals, which reflect the amounts frequencies and intensities appropriate to the objective of the treatment. 

TN No.: 21-0006 Approval Date:_____________ Effective Date: October 1, 2020 Supercedes TN No.: 16-0010 Attachment 3.1-A Page 29C-23 STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND D. Partial Hospitalization (1) Definition of Service: Partial Hospitalization treatment is a short-term, outpatient psychiatric treatment service that parallels the intensity of services provided in a hospital, including medical and nursing supervision and interventions. Partial Hospitalization is a more intense form of treatment than Intensive Outpatient Services and serves as an alternative to inpatient care when the participants can safely reside in the community. Participants who require at least 20 hours of structured outpatient treatment per week, delivered in half or full day sessions, are eligible to receive Partial Hospitalization services. (2) Service Requirements: Before providing Partial Hospitalization Services, the provider must develop a written individualized treatment plan, in conjunction with the participant based on the comprehensive assessment. This plan shall be updated as clinically appropriate, reviewed and approved by a licensed physician or licensed practitioner of the healing arts, within the scope of his or her practice under State law, and shall include the following requirements: x An assessment of the participant’s individual needs; and x The participant’s treatment plan goals; and x Specific interventions for meeting the treatment plan goals which reflect the amounts frequencies and intensities appropriate to the objective of the treatment. E. Opioid Maintenance Therapy: Service moved to 1905(a)(29) Medication Assisted Treatment Supplement to Attachment 3.1-A. Reserve for future use. From October 1, 2020 through September 30, 2025, medication assisted treatment (MAT) to treat opioid use disorder (OUD) as defined at section 1905(ee)(1) of the Social Security Act is covered exclusively in Supplement to Attachment 3.1-A for 1905(a)(29). 

TN No.: 21-0006 Approval Date:_____________ Effective Date: October 1, 2020 Supercedes TN No.: 16-0010 Attachment 3.1-A Page 29C-24 STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND F. Medication assisted treatment services for participants with substance use disorders other than opioid use disorder: From October 1, 2020 through September 30, 2025, medication assisted treatment (MAT) to treat opioid use disorder (OUD) as defined at section 1905(ee)(1) of the Social Security Act is covered exclusively in Supplement to Attachment 3.1-A for 1905(a)(29). (1) Definition of Service: Medication assisted treatment uses pharmacological interventions as part of a treatment program for participants with substance use disorders other than opioid use disorder. Medication assisted treatment includes: x Point of care toxicology x Periodic medications x Periodic medication management visits for substance use disorder symptom reduction or withdrawal management. (2) Service Requirements: Before providing medication assisted treatment, the provider must develop a written individualized treatment plan, in conjunction with the participant based on the comprehensive assessment. This plan shall be updated as clinically appropriate, reviewed and approved by a licensed physician or licensed practitioner of the healing arts, within the scope of his or her practice under State law, and shall include the following requirements: x An assessment of the participant’s individual needs; and x The participant’s treatment plan goals. G. Ambulatory Withdrawal Management (1) Definition of Service: Ambulatory Withdrawal Management is a service provided to acutely intoxicated participants to manage withdrawal syndromes. Ambulatory Withdrawal Management includes: x Physical examinations. x Initial and periodic comprehensive substance use disorder assessments including an assessment of drug and alcohol use, as well as substance use disorder treatment history. It shall also include referrals for physical and mental health services; and a recommendation for the appropriate level of substance 

TN No.: 21-0006 Approval Date:_____________ Effective Date: October 1, 2020 Supercedes TN No.: 16-0010 Attachment 3.1-A Page 29C-25 STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND use disorder treatment. x Managing withdrawal symptoms including administration and monitoring of medications. x Monitoring of vital signs. x Assisting in motivating the individual to participate in an appropriate treatment program for alcohol and other drug dependence. (2) Service Requirements: Before providing Ambulatory Withdrawal Management services, the provider must develop a comprehensive assessment. This plan shall be reviewed and approved by a licensed physician or licensed practitioner of the healing arts, within the scope of his or her practice under State law, shall include all of the following requirements: x An assessment of the participant’s individual needs; and x The participant’s treatment plan goals. Practitioners and entities by service type: A. Comprehensive substance use disorder assessment: (1) Opioid Treatment Programs (OTPs) provide comprehensive substance use disorder assessments utilizing appropriately licensed and certified alcohol and drug counselors. (2) Community-based outpatient treatment service providers provide comprehensive substance use disorder assessments utilizing appropriately licensed and certified alcohol and drug counselors. B. Group and individual substance use disorder counseling services: (1) OTPs provide group and individual substance use disorder counseling services utilizing appropriately licensed and certified alcohol and drug counselors. (2) Community-based outpatient treatment service providers provide group and individual substance use disorder counseling services utilizing appropriately licensed and certified alcohol and drug counselors. C. Intensive outpatient services: 

TN No.: 21-0006 Approval Date:_____________ Effective Date: October 1, 2020 Supercedes TN No.: 16-0010 Attachment 3.1-A Page 29C-26 STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND (1) Community-based outpatient treatment service providers may provide intensive outpatient services utilizing appropriately licensed and certified alcohol and drug counselors. D. Partial hospitalization services: (1) Community-based outpatient treatment service providers may provide partial hospitalization services utilizing appropriately licensed and certified alcohol and drug counselors. E. Opioid maintenance therapy services: Service moved to 1905(a)(29) Medication Assisted Treatment Supplement to Attachment 3.1-A. Reserve for future use. From October 1, 2020 through September 30, 2025, medication assisted treatment (MAT) to treat opioid use disorder (OUD) as defined at section 1905(ee)(1) of the Social Security Act is covered exclusively in Supplement to Attachment 3.1-A for 1905(a)(29). F. Medication assisted treatment services for participants with substance use disorders other than opioid use disorder: (1) Individually licensed physicians, nurse practitioners, and physician’s assistants. Practitioner and Provider Qualifications: A. Individual Practitioner Qualifications: (1) Licensed and certified alcohol and drug counselors x Licensed clinical alcohol and drug counselor: licensed by the State Board of Professional Counselors and Therapists (2) Physicians: licensed by the Maryland Board of Physicians (3) Physician assistants: Licensed by the Maryland Board of Physicians (4) Nurse practitioners: Licensed by the Maryland Board of Nursing (5) Registered nurses: Licensed by the Maryland Board of Nursing B. Provider Qualifications: 

TN No.: 21-0006 Approval Date:_____________ Effective Date: October 1, 2020 Supercedes TN No.: 16-0010 Attachment 3.1-A Page 29C-27 STATE PLAN FOR MEDICAL ASSISTANCE UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF MARYLAND (1) Community-based Outpatient Treatment Providers: x Licensed by the designated state agency to provide SUD treatment services. x Agencies providing MAT are required to employ or contract with licensed physicians, nurse practitioners, or physician’s assistants operating under the supervision of a licensed physician. x Agencies providing outpatient counseling services are required to employ or contract with licensed clinical alcohol and drug counselors in accordance with practitioner qualifications in (A)(1) above. (2) Opioid Treatment Providers: x Defined in 1905(a)(29) Medication Assisted Treatment Supplement to Attachment 3.1-A. From October 1, 2020 through September 30, 2025, medication assisted treatment (MAT) to treat opioid use disorder (OUD) as defined at section 1905(ee)(1) of the Social Security Act is covered exclusively in Supplement to Attachment 3.1-A for 1905(a)(29). x Opioid treatment providers are able to provide services for non-OUD treatment under professional license as designated by the state. Limitations: x All services require prior authorization by the Department or its designee prior to service delivery and all services are subject to approval based on medical necessity. 

Attachment 3.1-A Page 29C-29 State of Maryland 1905(a)(29) Medication-Assisted Treatment (MAT) Citation: 3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued) 1905(a)(29) MAT as described and limited in Attachment 3.1-A. ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy. TN# 21-0006

Approval Date: __________ Effective Date: October 1, 2020 Supersedes TN# NEW i. General Assurance MAT is covered under the Medicaid state plan for all Medicaid beneficiaries who meet the medical necessity criteria for receipt of the service for the period beginning October 1, 2020, and ending September 30, 2025. ii. Assurances a. The state assures coverage of Naltrexone, Buprenorphine, and Methadone and all of the forms of these drugs for MAT that are approved under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) and all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262). b. The state assures that Methadone for MAT is provided by Opioid Treatment Programs that meet the requirements in 42 C.F.R. Part 8. c. The state assures coverage for all formulations of MAT drugs and biologicals for OUD that are approved under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) and all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262). iii. Service Package The state covers the following counseling services and behavioral health therapies as part of MAT. a) Please set forth each service and components of each service (if applicable), along with a description of each service and component service. 

Attachment 3.1-A Page 29C-30 State of Maryland 1905(a)(29) Medication-Assisted Treatment (MAT) Citation: 3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued) 1905(a)(29) MAT as described and limited in Attachment 3.1-A. ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy. TN# 21-0006

Approval Date: __________ Effective Date: October 1, 2020 Supersedes TN# NEW From October 1, 2020, through September 30, 2025, the state assures that MAT to treat OUD as defined at section 1905(ee)(1) of the Social Security Act (the Act) is covered exclusively under section 1905(a)(29) of the Act. i) Comprehensive assessment for participants with opioid use disorder: (1) Definition of Service: A comprehensive assessment is a process of determining a participant’s current health status and relevant history in areas including opioid use, mental health, social supports, and somatic health. Providers use a comprehensive assessment to establish the type and intensity of services participants will need to adequately address their opioid use disorder. (2) Service Requirements: Comprehensive assessment at a minimum shall be reviewed and approved by a licensed physician or licensed practitioner of the healing arts, within the scope of his or her practice under State law, and shall include an assessment of current opioid use and opioid use disorder treatment history.. It shall also include referrals for physical and mental health services; and a recommendation for the appropriate service for opioid use disorder treatment. ii) Group and individual opioid use disorder counseling services: (1) Definition of Service: Individual and group counseling sessions involve evidence- based psychotherapeutic interventions. Cognitive- behavioral, motivational, and insight- based techniques are used according to each participant’s needs. The therapeutic style is client-centered and flexible. Treatment 

Attachment 3.1-A Page 29C-31 State of Maryland 1905(a)(29) Medication-Assisted Treatment (MAT) Citation: 3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued) 1905(a)(29) MAT as described and limited in Attachment 3.1-A. ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy. TN# 21-0006

Approval Date: __________ Effective Date: October 1, 2020 Supersedes TN# NEW usually involves a combination of individual and group counseling. The primary goals of treatment are to: Ɣ Develop skills to enable individuals to abstain from all opioids Ɣ Develop relapse prevention strategies through family and/or other support networks; and Ɣ Engage participants in long-term recovery strategies. (2) Service Requirements: Before providing services described in this section, the provider shall develop a written individualized treatment plan, in conjunction with the participant based on the comprehensive assessment. This plan which shall be updated as clinically appropriate, shall be reviewed and approved by a licensed physician or licensed practitioner of the healing arts within the scope of his or her practice under State law, and shall include: Ɣ An assessment of the participant’s individual needs; and Ɣ The participant’s treatment plan goals. b) Please include each practitioner and provider entity that furnishes each service and component service. i) Comprehensive assessment for participants with an opioid use disorder: (1) Opioid Treatment Programs (OTPs) provide comprehensive assessments utilizing appropriately licensed and certified alcohol and drug counselors. (2) Community-based outpatient treatment service providers 

Attachment 3.1-A Page 29C-32 State of Maryland 1905(a)(29) Medication-Assisted Treatment (MAT) Amount, Duration, and Scope of Medical and Remedial Care Services Provided to the Categorically Needy (continued) TN# 21-0006

Approval Date: __________ Effective Date: October 1, 2020 Supersedes TN# NEW provide comprehensive assessments utilizing appropriately licensed and certified alcohol and drug counselors. ii) Group and individual opioid use disorder counseling services: (1) OTPs provide group and individual opioid use disorder counseling services utilizing appropriately licensed and certified alcohol and drug counselors. (2) Community-based outpatient treatment service providers provide group and individual opioid use disorder counseling services utilizing appropriately licensed and certified alcohol and drug counselors. c) Please include a brief summary of the qualifications for each practitioner or provider entity that the state requires. Include any licensure, certification, registration, education, experience, training and supervisory arrangements that the state requires. i) Practitioner and Provider Qualifications: (1) Licensed and certified alcohol and drug counselors: Ɣ Licensed clinical alcohol and drug Counselor: licensed by the State Board of Professional Counselors and Therapists (2) Physicians: licensed by the Maryland Board of Physicians (3) Physician assistants: licensed by the Maryland Board of Physicians (4) Nurse practitioners: licensed by the Maryland Board of Nursing (5) Registered nurses: licensed by the Maryland Board of Nursing (6) Data 2000 Waived Practitioners: physicians and nurse practitioners, and physician’s Assistants granted a DATA 2000 waiver from the separate registration requirements of 

Attachment 3.1-A Page 29C-33 State of Maryland 1905(a)(29) Medication-Assisted Treatment (MAT) Citation: 3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued) 1905(a)(29) MAT as described and limited in Attachment 3.1-A. ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy. TN# 21-0006

Approval Date: __________ Effective Date: October 1, 2020 Supersedes TN# NEW the Narcotic Addict Treatment Act to treat opioid addiction with Schedule III, IV, and V opioid medications or combinations of such medications that have been specifically approved by the Food and Drug Administration for that indication. ii) Community-based Outpatient Treatment Providers: Ɣ Licensed by the designated state agency to provide OUD treatment services Ɣ Providers that provide MAT must employ or contract with DATA 2000 Waived practitioners Ɣ Providers that provide group and individual opioid use disorder counseling services are required to employ or contract with licensed clinical alcohol and drug counselors in accordance with practitioner qualifications in (c)(i) above. iv. Utilization Controls __X___ The state has drug utilization controls in place. (Check each of the following that apply) __X___ Generic first policy __X___ Preferred drug lists __X___ Clinical criteria __X___ Quantity limits _____ The state does not have drug utilization controls in place 

Attachment 3.1-A Page 29C-34 State of Maryland 1905(a)(29) Medication-Assisted Treatment (MAT) Citation: 3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued) 1905(a)(29) MAT as described and limited in Attachment 3.1-A. ATTACHMENT 3.1-A identifies the medical and remedial services provided to the categorically needy. TN# 21-0006

Approval Date: __________ Effective Date: October 1, 2020 Supersedes TN# NEW v. Limitations Describe the state’s limitations on amount, duration, and scope of MAT drugs, biologicals, and counseling and behavioral therapies related to MAT. x All services require prior authorization by the Department or its designee prior to service delivery and all services are subject to approval based on medical necessity. x The Department has quantity limits over time and daily maximum dose limits for several of the MAT drugs. For a complete listing of these limitations please visit this address: https://mmcp.health.maryland.gov/pap/docs/QL.pdf. PRA Disclosure Statement - This information is being collected to assist the Centers for Medicare & Medicaid Services in implementing section 1006(b) of the SUPPORT for Patients and Communities Act (P.L. 115-271) enacted on October 24, 2018. Section 1006(b) requires state Medicaid plans to provide coverage of Medication-Assisted Treatment (MAT) for all Medicaid enrollees as a mandatory Medicaid state plan benefit for the period beginning October 1, 2020, and ending September 30, 2025. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 # 60). Public burden for all of the collection of information requirements under this control number is estimated to take about 80 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244- 1850. 

TN# 21-0006

Approval Date: ___________ Effective Date: October 1, 2020 Supersedes TN# 18-0002 Attachment 4.19B Page 17 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of Maryland Community-Based Substance Use Disorder Services Reimbursement Methodology 1. A. The Department’s reimbursement methodology for community-based substance use disorder services is fixed rate. Rates were set as of April 4th, 2017 and are effective for services on or after that date. All providers must be licensed by the designated state agency to provide SUD treatment services and shall meet the requirements established by the Department. Services are limited to those outlined in 3.1.A Section 13d.V of the Maryland State Plan. Providers will be paid the lower of the provider’s customary fee schedule to the general public or the published fee schedule. B. All providers described in 1a, both government and non-government, are reimbursed pursuant to the same fee schedule. Providers are paid by HCPCS codes and the rates are based on the rate that Maryland Medicaid reimburses its specialty mental health providers for similar services. The fee schedule for community-based substance use disorder providers is reviewed for updating every state fiscal year as determined by state of Maryland legislation. A link to the published fee schedule can be found by going to the Behavioral Health Information section of https://mmcp.health.maryland.gov/Pages/Provider-Information.aspx, clicking on the “PBHS Fee Schedule,” and selecting “PBHS SUD Fee Schedule.” 

TN# 21-0006 Approval Date: Effective Date: October 1, 2020 Supersedes TN# 16-0010 Attachment 4.19B Page 17A STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of Maryland 1905(a)(29) Medication-Assisted Treatment (MAT) Reimbursement Methodology 1. A. The Department’s reimbursement methodology for community-based opioid use disorder (OUD) services is a fixed rate. Rates were set as of April 4th, 2017 and are effective for services on or after that date. All providers must be licensed by the designated state agency to provide OUD treatment services and shall meet the requirements established by the Department. Services are limited to those outlined in Supplement to Attachment 3.1A for 1905(a)(29). Providers will be paid the lower of the provider’s customary fee schedule to the general public or the published fee schedule. From October 1, 2020, through September 30, 2025, the state assures that medication assisted treatment (MAT) to treat opioid use disorder (OUD) as defined at section 1905(ee)(1) of the Social Security Act (the Act) is covered exclusively under section 1905(a)(29) of the Act. B. Reimbursement for unbundled MAT prescribed drugs and biologicals used to treat opioid use disorder (OUD) is reimbursed in accordance with the reimbursement methodologies for covered outpatient legend and non legend drugs found in Attachment 4.19-B, pages 35-35a, Section A for both dispensed and administered prescribed drugs. C. All providers described in 1a, both government and non-government, are reimbursed pursuant to the same fee schedule. Providers are paid by HCPCS codes and the rates are based on the rate that Maryland Medicaid reimburses its specialty mental health providers for similar services. The fee schedule for community-based substance use disorder providers is reviewed for updating every state fiscal year as determined by state of Maryland legislation. A link to the published fee schedule can be found by going to the Behavioral Health Information section of https://mmcp.health.maryland.gov/Pages/Provider-Information.aspx, clicking on the “PBHS Fee Schedule,” and selecting “PBHS SUD Fee Schedule.” 

Table of Contents

State/Territory Name: MD State Plan Amendment (SPA) #: 22-0019 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

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

December 14, 2022

Steven Schuh Medicaid Director Maryland Department of Health 201 W. Preston Street, 5th Floor Baltimore, MD 21201

Re: Maryland State Plan Amendment (SPA) 22-0019

Dear Director Schuh:

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) MD-22-0019. 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.

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 Maryland 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) (to waive) of the Act, as applicable, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. These waivers or modifications of the requirements related to SPA submission timelines and public notice 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 informs you that Maryland’s Medicaid SPA Transmittal Number 22-0019 is approved effective July 1, 2022. This SPA is in addition to all previous approved Disaster Relief SPAs, 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. Please contact Talbatha Myatt at (215) 861-4259 or by email at Talbatha.Myatt@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Maryland and the healthcare community.

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

Center for Medicaid and CHIP Services Enclosures Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2022.12.15 15:15:55 -05'00'

DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED ‘OMB No. 0938-0193

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

1. TRANSMITTAL NUMBER 2. STATE 2.2 —0 01 9 MD

3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT © xx_ © xx

TO: CENTER DIRECTOR

4, PROPOSED EFFECTIVE DATE

CENTERS FOR MEDICAID & CHIP SERVICES July 1. 2022 DEPARTMENT OF HEALTH AND HUMAN SERVICES yi, 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) Sections 1135(b) and 1902 of the Social Security Act a FFY__2022 $_0 b FFY 2023 $_0

7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 7.4, +46, pages +42422 Re 112-120 new

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

9. SUBJECT OF AMENDMENT: Resource disregard for ABD groups during the Public Health Emergency (PHE); a new disregard during the 12-month period after the end of the PHE;

waiver of 42 CFR 435.907(f) for the 12-month period after the end of the PHE. The SPA also includes,

dispensing of drugs, the waiver to permit provision of a 14-day emergency supply, instead of a 72-hour emergency supply of prescribed drug, and the waiver of prior authorization requirements for non-

effective March 21, 2020 through August 15, 2021, the waiver of any signature requirements for the

Hie Health -E:

10. GOVERNOR'S REVIEW (Check One)

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

© oTHER, ASSPECIFIED:

Tricia Roddy

13. TITLE Deputy Medicaid Director

14. DATE SUBMITTED 9/13/22

15. RETURN TO

Steven Schuh

Medicaid Director

Maryland Department of Health 201 W. Preston St., 5th Floor Baltimore, MD 21201

FOR CMS

USE ONLY

16. DATE RECEIVED 09/16/2022

17. DATE APPROVED 12/14/2022

PLAN APPROVED - ONE COPY ATTACHED

18. EFFECTIVE DATE OF APPROVED MATERIAL 07/01/2022

Digitally signed by Alissa M. Deboy -S

Date: 2022.12.15 15:16:12 -05'00"

19. SIGNATURE OF APPROVINIESQEFIGIAL Deboy -S

20. TYPED NAME OF APPROVING OFFICIAL

Alissa Mooney DeBoy

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

Center for Medicaid and CHIP Services

22. REMARKS

12-8 -22 and 12-13-22- The state requested the following pen & ink changes: Box 15-add contact Steven Schuh Box 7- Delete 7.4C and update SPA page number to reflect 112-120 (NEW)

Box 9- update the Subject to reflect : Resource disregard for ABD groups during the Public Health Emergency (PHE); a new disregard during the 12-month period after the end of the PHE; waiver of 42 CFR 435.907(f) for the 12-month period after the end of the PHE. The SPA also includes, effective March 21, 2020 through August 15, 2021, the waiver of any signature requirements for the dispensing of drugs, the waiver to permit provision of a 14-day emergency supply, instead of a 72-hour emergency supply of prescribed drug, and the waiver of prior authorization requirements for non-preferred drugs.

FORM CMS-179 (09/24)

Instructions on Back

State/Territory: Maryland Page 112 TN: _22Ͳ0019 Supersedes TN: New Approval Date: Effective Date: July 1, 2022 Describe shorter period here. Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVIDͲ19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVIDͲ19 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 COVIDͲ19 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 COVIDͲ19 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 COVIDͲ19 outbreak (or any renewals thereof), or for any shorter period described below: 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). 7KLV 63$ LV LQ DGGLWLRQ WR DOO SUHYLRXVO\ DSSURYHG 'LVDVWHU 5HOLHI 63$V DQG GRHV QRW VXSHUVHGH DQ\WKLQJ DSSURYHG LQ WKRVH 63$V ĞĐĞŵďĞƌ ϭϰ͕ ϮϬϮϮ

State/Territory: Maryland Page 113 TN: _22Ͳ0019 Supersedes TN: New Approval Date: Effective Date: _July 1, 2022 Please describe the modifications to the timeline. Include name of the optional eligibility group and applicable income and resource standard. c. Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in [insert name of state] Medicaid state plan, as described below: 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. 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: ͲorͲ b. Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: 3. x The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies: 7KLV 63$ LV LQ DGGL LRQ WR DOO SUHYLRXVO\ DSSURYHG 'LVDVWHU 5HOLHI 63$V DQG GRHV QRW VXSHUVHGH DQ\WKLQJ DSSURYHG LQ WKRVH 63$V ĞĐĞŵďĞƌ ϭϰ͕ ϮϬϮϮ

State/Territory: Maryland Page 114 TN: _22Ͳ0019 Supersedes TN: New Approval Date: Effective Date: _July 1, 2022 Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. 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 nonͲresidents: 6. The agency provides for an extension of the reasonable opportunity period for nonͲ citizens declaring to be in a satisfactory immigration status, if the nonͲcitizen 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 90Ͳday reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. 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. Disregard as a resource income that would otherwise have been part of an individual’s liability for his or her institutional or homeͲ and communityͲbased waiver services based on application of the postͲeligibility treatmentͲofͲincome (PETI) rules but which became countable resources on or after March 18, 2020 for the following nonͲMAGI groups: Qualified Medicare Beneficiaries, 1902(a)(10)(E)(i) Special LowͲincome Medicare Beneficiaries, 1902(a)(10)(E)(iii) Qualifying Individuals, 1902(a)(10)(E)(iv) Individuals eligible for but not receiving cash assistance, 1902(a)(10)(A)(ii)(I) Individuals eligible for cash assistance but for institutionalization, 42 CFR 435.211 HCBS waiver participants under a Special Income Level, 42 CFR 435.217 NF residents under a Special Income Level, 1902(a)(10)(A)(ii)(V) Medically needy individuals eligible based on age, blindness, or disability 42 CFR 435.320, 435.322, 435.324 7KLV 63$ LV LQ DGGLWLRQ WR DOO SUHYLRXVO\ DSSURYHG 'LVDVWHU 5HOLHI 63$V DQG GRHV QRW VXSHUVHGH DQ\ KLQJ DSSURYHG LQ WKRVH 63$V ĞĐĞŵďĞƌ ϭϰ͕ ϮϬϮϮ

State/Territory: Maryland Page 115 TN: _22Ͳ0019 Supersedes TN: New Approval Date: Effective Date: _July 1, 2022 Please describe any limitations related to the populations included or the number of allowable PE periods. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 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 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. 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. 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 MAGIͲ 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 callͲcenters or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: 7KLV 63$ LV LQ DGGLWLRQ WR DOO SUHYLRXVO\ DSSURYHG 'LVDVWHU 5HOLHI 63$V DQG GRHV QRW VXSHUVHGH DQ\ KLQJ DSSURYHG LQ WKRVH 63$V ĞĐĞŵďĞƌ ϭϰ͕ ϮϬϮϮ

State/Territory: Maryland Page 116 TN: _22Ͳ0019 Supersedes TN: New Approval Date: Effective Date: _July 1, 2022 Please list the applicable eligibility groups or populations. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship. 2. The agency suspends enrollment fees, premiums and similar charges for: a. All beneficiaries b. The following eligibility groups or categorical populations: 3. The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Section D – Benefits Benefits: 1. The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. The agency makes the following adjustments to benefits currently covered in the state plan: 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). 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). 7KLV 63$ LV LQ DGGLWLRQ WR DOO SUHYLRXVO\ DSSURYHG 'LVDVWHU 5HOLHI 63$V DQG GRHV QRW VXSHUVHGH DQ\WKLQJ DSSURYHG LQ KRVH 63$V ĞĐĞŵďĞƌ ϭϰ͕ ϮϬϮϮ

State/Territory: Maryland Page 117 TN: _22Ͳ0019 Supersedes TN: New Approval Date: Effective Date: _July 1, 2022 Please describe. Please describe. State is requesting the following flexibilities effective March 21, 2020, through August 15, 2021: 1. Waiver of any signature requirements for the dispensing of drugs; 2. Waiver to permit provision of a 14Ͳday emergency supply, instead of a 72Ͳhour emergency supply, of the prescribed drug; and 3. Waiver of prior authorization requirements for nonͲpreferred drugs. Please describe the manner in which professional dispensing fees are adjusted. 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). a. The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Telehealth: 5. The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Drug Benefit: 6. X 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. 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. 7KLV 63$ LV LQ DGGL LRQ WR DOO SUHYLRXVO\ DSSURYHG 'LVDVWHU 5HOLHI 63$V DQG GRHV QRW VXSHUVHGH DQ\WKLQJ DSSURYHG LQ WKRVH 63$V ĞĐĞŵďĞƌ ϭϰ͕ ϮϬϮϮ

State/Territory: Maryland Page 118 TN: _22Ͳ0019 Supersedes TN: New Approval Date: Effective Date: July 1, 2022 Describe methodology here. Please list all that apply. Please describe criteria. Please describe. 9. The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multiͲsource drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. Newly added benefits described in Section D are paid using the following methodology: a. Published fee schedules – Effective date (enter date of change): Location (list published location): b. Other: Increases to state plan payment methodologies: 2. The agency increases payment rates for the following services: a. Payment increases are targeted based on the following criteria: b. Payments are increased through: i. A supplemental payment or addͲon within applicable upper payment limits: ii. An increase to rates as described below. 7KLV 63$ LV LQ DGGLWLRQ WR DOO SUHYLRXVO\ DSSURYHG 'LVDVWHU 5HOLHI 63$V DQG GRHV QRW VXSHUVHGH DQ\WKLQJ DSSURYHG LQ WKRVH 63$V ĞĐĞŵďĞƌ ϭϰ͕ ϮϬϮϮ

State/Territory: Maryland Page 119 TN: _22Ͳ0019 Supersedes TN: New Approval Date: Effective Date: July 1, 2022 Please describe. Describe telehealth payment variation. Please describe. Rates are increased: 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: Payment for services delivered via telehealth: 3. For the duration of the emergency, the state authorizes payments for telehealth services that: a. Are not otherwise paid under the Medicaid state plan; b. Differ from payments for the same services when provided face to face; c. Differ from current state plan provisions governing reimbursement for telehealth; d. Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. Ancillary cost associated with the originating site for telehealth is incorporated into feeͲforͲservice rates. ii. Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. Other payment changes: 7KLV 63$ LV LQ DGGLWLRQ WR DOO SUHYLRXVO\ DSSURYHG 'LVDVWHU 5HOLHI 63$V DQG GRHV QRW VXSHUVHGH DQ\WKLQJ DSSURYHG LQ WKRVH 63$V ĞĐĞŵďĞƌ ϭϰ͕ ϮϬϮϮ

State/Territory: Maryland Page 120 TN: _22Ͳ0019 Supersedes TN: New Approval Date: Effective Date: _July 1, 2022 Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section F – PostͲEligibility Treatment of Income 1. The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. The individual’s total income b. 300 percent of the SSI federal benefit rate c. Other reasonable amount: 2. The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: 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 0938Ͳ1148 (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 C4Ͳ26Ͳ05, Baltimore, Maryland 21244Ͳ1850. ***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 410Ͳ786Ͳ3870. 7KLV 63$ LV LQ DGGLWLRQ WR DOO SUHYLRXVO\ DSSURYHG 'LVDVWHU 5HOLHI 63$V DQG GRHV QRW VXSHUVHGH DQ\WKLQJ DSSURYHG LQ WKRVH 63$V ĞĐĞŵďĞƌ ϭϰ͕ ϮϬϮϮ

Table of Contents State/Territory Name: 0DU\ODQG State Plan Amendment (SPA) #: 

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 December 14, 2022 Steven Schuh Maryland Department of Health 201 W. Preston St., 5th Floor Baltimore, MD 21201 Re: Maryland State Plan Amendment (SPA) MD-22-0019-A Dear Mr. Schuh: The Centers for Medicare & Medicaid Services (CMS) reviewed the proposed Medicaid State Plan Amendment (SPA) RULJLQDOO\ submitted under transmittal number (TN) MD-22-0019 63$  proposes to temporarily implement a disregard of income that would have otherwise been part of an individual’s liability for institutional or home and community-based waiver services based on application of the post-eligibility treatment-of income (PETI) rules, but which became countable resources on or after March 18, 2020, originally approved in Disaster Relief SPA 22-0019. %HFDXVH WKH VWDWH DOVR ZDQWHG WR H[WHQG WKLV SURYLVLRQ EH\RQG WKH HQG RI WKH &29,' 3XEOLF +HDOWK (PHUJHQF\ 3+( SHULRG LW FUHDWHG 0' $ WR GR VR 0' $ LV WKH VXEMHFW RI WKLV DSSURYDO OHWWHU CMS conducted our review of your submittal according to statutory requirements in Title XIX of the Act and implementing regulations. This letter is to inform you that Maryland’s Medicaid SPA Transmittal Number 22-0019-A is approved effective the day after the end of the PHE. If you have any questions, please contact Talbatha Myatt at 215-861-4259 or via email at Talbatha.Myatt@cms.hhs.gov. Sincerely, Alissa Mooney DeBoy On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid and CHIP Services Enclosures Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2022.12.15 15:17:11 -05'00'

DEPARTMENT OF HEALTH ANDHUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES (OMB No. 0938-0193 1. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF 2 2 _00 1 9A MD STATE PLAN MATERIAL ——

FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES "SECURTTYACT “(@). x TITLE We! SOCIAL XIX XXl

TO: CENTER DIRECTOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES duly +2022 Day after the end of PHE 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) Sections 1135(b) and 1902 of the Social Security Act a FFY__2022 $_0 b FFY 2023 $_0 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 7-4 7-4-G_pages 442 422 ne OR ATTACHMENT (If Applicable)

Attachment 7.4.B page 1

9. SUBJECT OF AMENDMENT: Resouros disregard for ABD groups during the Public

Feslth Emergency (PHE); a new disregard during the 12-month period after the end of the PHE;

10. GOVERNOR'S REVIEW (Check One) O GOVERNOR'S OFFICE REPORTED NO COMMENT © OTHER, AS SPECIFIED:

COMMENTS OF GOVERNOR'S OFFICE ENCLOSED O NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

IAL 15. RETURN TO Steven Schuh Medicaid Director Maryland Department of Health Tricia hocdy 201 W. Preston St., 5th Floor 13.TITLE Baltimore, MD 21201 Deputy Medicaid Director 14. DATE SUBMITTED 9/13/22 FOR CMS USE ONLY 16. DATE RECEIVED 17. DATE APPROVED 09/16/2022 12/14/2022 PLAN APPROVED - ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 19. SIGNATURE OF APPROVING OFFICIAL Day after the end of the PHE (MECOLMEE SY = BEE s Date: 2022.12.15 15:17:27 0500 20. TYPED NAME OF APPROVING OFFICIAL 21. TITLE OF APPROVING OFFICIAL Alissa Mooney DeBoy On Behalf of Anne Marie Costello | Deputy Director, Center for Medicaid and CHIP Services

22. REMARKS

12-8 -22 and 12-13-22- The state requested the following pen & ink changes: Box 1- update Transmittal number to reflect MD-22-0019 A; Box 4-u date effective date to reflect Da after the end of PHE Box 15-add contact Steven Schuh; Box 7- delete 74 and update SPA pag bers te reflect 42-492 (NEW delete 7.4-C and 7.4 SPA page

numbers to reflect 1112-1222(NEW); Add 7.4.B page number 1; Box 9- update the Subject to reflect : Resource disregard for ABD groups during the Public Health Emergency (PHE); a new disregard during the 12-month period after the end of the PHE; waiver of 42 GRR 435: STAY, for the 12-month period after the end of the PHE. The SPA al ludes_offective March 24 2090 thrau h A £45 9094 thy uir ts §

fF the, $1, it £, if did P ui

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

1

7.4.B Temporary Extension to the Disaster Relief Policies in effect following the COVID-19 National Emergency

Effective the day after the end of the PHE until the last day of the twelfth month after the end of the PHE, the agency temporarily extends the following election of section 7.4 (approved on 12/15/2022 in SPA Number MD-22-0019) of the state plan:

Section A – Eligibility

3 x The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows.

Less restrictive resource methodologies:

TN: _22-0019-A

Approval Date: 12/14/2022 Effective Date: Day after the end of the PHE Supersedes TN: New

Disregard as a resource income that would otherwise have been part of an individual’s liability for his or her institutional or home- and community-based waiver services based on application of the post-eligibility treatment-of-income (PETI) rules but which became countable resources on or after March 18, 2020 for the following non-MAGI groups:

Qualified Medicare Beneficiaries, 1902(a)(10)(E)(i) Special Low-income Medicare Beneficiaries, 1902(a)(10)(E)(iii) Qualifying Individuals, 1902(a)(10)(E)(iv) Individuals eligible for but not receiving cash assistance, 1902(a)(10)(A)(ii)(I) Individuals eligible for cash assistance but for institutionalization, 42 CFR 435.211 HCBS waiver participants under a Special Income Level, 42 CFR 435.217 NF residents under a Special Income Level, 1902(a)(10)(A)(ii)(V) Medically needy individuals eligible based on age, blindness, or disability 42 CFR 435.320, 435.322, 435.324

Such resources will be disregarded through the twelve months following the end of the month in which the COVID-19 public health emergency ends.

Table of Contents State/Territory Name: Maryland State Plan Amendment (SPA) #: 23-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All MD - Submission Package - MD2023MS0003O - (MD-23-0005) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services June 23, 2023 Tricia Roddy Acting Medicaid Director Maryland Department of Health 201 West Preston Street 5th Floor Baltimore, MD 21201 Re: Approval of State Plan Amendment MD-23-0005 Dear Tricia Roddy, On March 29, 2023, the Centers for Medicare and Medicaid Services (CMS) received Maryland State Plan Amendment (SPA) MD-23-0005, in which the state proposed to adopt the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002. We approve Maryland State Plan Amendment (SPA) MD-23-0005 with an effective date(s) of January 01, 2023. If you have any questions regarding this amendment, please contact Talbatha Myatt at Talbatha.Myatt@cms.hhs.gov Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services CMS Cf US JOR MEDICARE &MEDICAJO SIIMCES

Records / Submission Packages - View All MD - Submission Package - MD2023MS0003O - (MD-23-0005) - Eligibility ⇐ All Reviewable Units Submission - Public Comment → View Compare Doc Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MD2023MS0003O | MD-23-0005 Spell Check Instructions | Request System Help CMS-10434 OMB 0938-1188 Not Started In Progress Complete Package Header Package ID MD2023MS0003O Submission Type Official Approval Date 06/23/2023 Superseded SPA ID N/A SPA ID MD-23-0005 Initial Submission Date 3/29/2023 Effective Date N/A View Implementation Guide State Information Collapse State/Territory Name: Maryland Medicaid Agency Name: Maryland Department of Health, Office of Health Care Financing Submission Component Collapse Submission Type Collapse Selecting Official Submission Package means that the official 90-day review period will start upon submission. Allow this official package to be viewable by other states? Key Contacts Collapse Name Title Phone Number Email Address Program Colomb, Tyler Medicaid Provider Services Administration (443)765-9379 tyler.colomb@maryland.gov Medicaid SPA ID and Effective Date Collapse SPA ID MD-23-0005 VIEW PRINT PREVIEW Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions VIEW ALL RESPONSES State Plan Amendment Medicaid CHIP Official Submission Package Draft Submission Package Yes No 0 0 0 0 0 0 0

Reviewable Unit Proposed Effective Date Superseded SPA ID Mandatory Eligibility Groups 1/1/2023 MD-18-0005 Former Foster Care Children 1/1/2023 MD-17-0003 Page Number of the Superseded Plan Section or Attachment (If Applicable): Executive Summary Collapse Summary Description Including Goals and Objectives SPA MD-23-0005 reflects Maryland's coverage of youth formerly in foster care, consistent with Section 1002(a) of the SUPPORT Act. Dependency Description Collapse Description of any dependencies between this submission package and any other submission package undergoing review Disaster-Related Submission Collapse This submission is related to a disaster Federal Budget Impact and Statute/Regulation Citation Collapse Federal Budget Impact Federal Fiscal Year Amount First 2023 $0 Second 2024 $0 Federal Statute / Regulation Citation The SUPPORT Act updated sec. 1902(a)(10)(A)(IX)(cc) and (dd) Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available Governor's Office Review Collapse Authorized Submitter Collapse The following information will be provided by the system once the package is submitted to CMS. Name of Authorized Submitter Tyler Colomb Phone number Yes No No comment Comments received No response within 45 days Other 0 0 0 0 0 0

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

Records / Submission Packages - View All MD - Submission Package - MD2023MS0003O - (MD-23-0005) - Eligibility ⇐ All Reviewable Units ← Submission - Tribal Input | Former Foster Care Children → View Compare Doc Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MD2023MS0003O | MD-23-0005 Spell Check Instructions | Request System Help CMS-10434 OMB 0938-1188 Not Started In Progress Complete Package Header Package ID MD2023MS0003O Submission Type Official Approval Date 06/23/2023 Superseded SPA ID MD-18-0005 User-Entered SPA ID MD-23-0005 Initial Submission Date 3/29/2023 Effective Date 1/1/2023 View Implementation Guide Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives APPROVED Pregnant Women APPROVED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children APPROVED Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled VIEW PRINT PREVIEW Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions

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Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneficiaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW Working Individuals under 1619(b) NEW Qualified Medicare Beneficiaries NEW Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries NEW Qualifying Individuals NEW B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group CONVERTED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244- 1850.

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Records / Submission Packages - View All MD - Submission Package - MD2023MS0003O - (MD-23-0005) - Eligibility ⇐ All Reviewable Units ← Mandatory Eligibility Groups View Compare Doc Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | MD2023MS0003O | MD-23-0005 Individuals under the age of 26, who were in foster care and on Medicaid when they turned age 18 or aged out of foster care. Spell Check Instructions | Request System Help CMS-10434 OMB 0938-1188 Not Started In Progress Complete Package Header Package ID MD2023MS0003O Submission Type Official Approval Date 06/23/2023 Superseded SPA ID MD-17-0003 User-Entered SPA ID MD-23-0005 Initial Submission Date 3/29/2023 Effective Date 1/1/2023 View Implementation Guide The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Collapse Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Were in foster care upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21). 3. Are described under either Section B. or C. B. Individuals Covered Collapse For individuals who turn 18 before January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. 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 ii. Enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration; and b. 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. 2. In addition to B.1., the state elects to cover 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: VIEW PRINT PREVIEW Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions VIEW ALL RESPONSES 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.

C. Individuals Covered Collapse For individuals who turn 18 on or after January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration; and b. Are not enrolled in mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. 2. In addition to C.1., the state elects to cover individuals who were in foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to a state under the unaccompanied refugee minor program) 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, and meet the following criteria: D. Additional Information (optional) Collapse PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244- 1850. 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. a. They were enrolled in Medicaid under a 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 a state's or Tribe's foster care assistance ends. b. They were placed by a 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 a state's or Tribe's foster care assistance ends. c. They were placed by a 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 a state's or Tribe's foster care assistance ends. □ □ □ □ □