Model Application Template for the State Children’s Health Insurance Program

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

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Model Application Template for the State Children’s Health Insurance Program

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

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

State/Territory:____________________Maine____________________________________ (Name of State/Territory)

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

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

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

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Christine Zukas-Lessard Position/Title: Deputy Director, Bureau of Medical Services Name: Robert Boschen

Position/Title: Director, Division of Financial & Reimbursement Services Name: Patricia Dushuttle Position/Title: SCHIP Coordinator

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 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

Model Application Template for the State Children’s Health Insurance Program

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Section 1 General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3.

A combination of both of the above. MaineCare is the umbrella term in use in the State of Maine to collectively refer to all benefits provided under previously separate program names such as Medicaid, SCHIP, CubCare, etc.. The name change (a Legislative mandate) is administrative in nature and represents no change in benefits or rights of beneficiaries.

MaineCare, with Title XIX funding, provides coverage to children from birth to 12 months of age in families with income through 185% of the federal poverty level (FPL), children ages 1 through 5 in families with income through 133% FPL, and children ages 6 through 18 in families with income through 125% FPL. With Title XXI funding, (under MaineCare expansion), MaineCare provides coverage to children ages 1 through 18 in families with income from 133%/125% through 150% of the FPL; and under a separate child health program (formerly “CubCare”) provides coverage to children from birth to 12 months of age in families with income from 186% through 200% of the FPL, and to children ages 1 through 18 in families with income from 151% through 200% of FPL.

1.2

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

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR

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part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

1.4 Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Date Plan Submitted:

May 19, 1998 Date Plan Approved:

August 7, 1998 Effective Date:

July 1, 1998 (Title XIX expansion)

August 1, 1998 (Title XXI)

Amendment #1: Cover birth-18 185%-200%; no AI/AN cost sharing Date Submitted:

January 5, 2000 Date Approved:

March 1, 2001 Date Effective:

October 1, 1999

Amendment #2: Hospice Date Submitted:

April 5, 2001 Date Approved:

June 6, 2001 Date Effective:

March 30, 2001

Amendment #3: Compliance Date Submitted:

June 28, 2002 Date Approved:

September 19, 2002

Amendment #4: Public health initiatives Date Submitted:

January 9, 2003 Date Approved:

April 16, 2003 Date Effective:

July 1, 2002

Amendment #5: Increase premiums for separate child health program Date Submitted:

October 6, 2004 Date Approved:

January 5, 2005 Date Effective:

November 1, 2004

Amendment #6: DirigoChoice Date Submitted:

June 29, 2005 Date Approved

September 22, 2005 Date Effective:

January 1, 2005

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

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

Currently, no public-private partnerships exist in Maine.

Between October-December 2002, the University of Southern Maine, Muskie School of Public Service conducted a random survey of Maine residents to estimate the numbers of individuals without health insurance or with inadequate insurance. At the time of the survey, about 60% of children had employer based coverage and 5% had coverage through individually purchased health plans. About 28% had public coverage (primarily MaineCare) and about 8% were uninsured.

According to the 2001-2003 Current Population Survey, uninsured children under age 19 below 200% of poverty as a percent of total children under age 19 is 3.6%.

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance):

Please see Section 5 for a description of outreach efforts.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

No public-private partnerships currently exist in Maine.

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2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

There are no public programs in the state, except MaineCare, that provide health care coverage for low-income children. The coordination of MaineCare with public health programs is accomplished through two major venues. The coordinator of SCHIP within the Bureau of Medical Services is an active participant on two major committees whose focus is the promotion of access to health care. The first, MaineCare Benefits for Members Under 21 Committee, meets periodically and is comprised of staff from the Bureau of Medical Services and Bureau of Health child-related programs such as: WIC, Public Health Nursing, Oral Health, and the Teen and Young Adult Health. The purpose of the group is to coordinate outreach and planning activities for promoting access to services across all programs. The second group, the Managed Care Implementation Task Force, is comprised of staff from the Bureau of Medical Services, Bureau of Family Independence, Bureau of Health and various advocacy groups within the State. The primary focus of the task force is on implementation of MaineCare managed care as well as other service delivery issues.

The SCHIP coordinator is also a participant on the Steering Committee and Statewide Coalition for the Robert Wood Johnson Covering Kids and Families Outreach Campaign. The Covering Kids and Families grantee in Maine is the Maine Primary Care Association and its partner agencies, Maine Equal Justice Partners, and Consumers for Affordable Health Care. The Steering Committee meets 6-8 times per year and provides overall direction to the Covering Kids and Families Outreach Campaign. The Statewide Coalition meets 3 times a year. The Coalition meetings are an opportunity for Coalition members to alert other members as to events taking place within the State, for local groups to apprise the group on activities occurring in their particular areas and for the group to discuss recommendations for future activities.

Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

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6 Approval Date: 3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

MaineCare, both Title XIX and Title XXI funded coverage, is administered by the Maine Department of Health and Human Services. Within the Department, the Bureau of Medical Services is responsible for establishing policy regarding benefits, quality assurance, and claims payment. The Bureau of Family Independence is responsible for determining eligibility.

Children covered under MaineCare with Title XXI funding are provided with the same rights and benefits available to children enrolled with Title XIX funding. All administrative processes are designed by the Department of Health and Human Services to be seamless. As such, all enrollment and eligibility processes, benefit package/benefit delivery policies, and outreach activities are the same for Title XIX and Title XXI, with the only discernable difference being premium billing for those Title XXI children at 151% through 200% FPL.

There are 3 delivery systems.

(1) The MaineCare primary care case management initiative is operational in all 16 counties. With few exceptions, the majority of MaineCare children covered under Title XXI funding access services through primary care case management.

(2) The MaineCare DirigoChoice initiative is operational in all 16 counties. MaineCare members may voluntarily enroll in DirigoChoice if they work for a DirigoChoice eligible business that offers the DirigoChoice plan to its employees and they meet the requirements of an eligible employee. MaineCare members who are dependents of DirigoChoice members may also enroll in DirigoChoice. DirigoChoice meets the conditions necessary to contract as a managed care entity as described in CFR 457.955.

(3) MaineCare members not participating in primary care case management or the DirigoChoice initiative can access services through the fee for service system.

In addition, pursuant to Section 2105(a)(1)(D), the Department will offer “health services initiatives” directed at children and adolescents age 18 or younger. The health services initiatives will be activities sponsored by the Department’s Bureau of Health and do not overlap with MaineCare school based health services.

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Specific health services initiatives include the following:

• grants to providers to promote health education in primary and secondary school through “school health coordinators” where the school health coordinators implement a coordinated school health program that incorporates the Center for Disease Control/Division of Adolescent and School Health (CDC/DASH) guidelines for tobacco use, physical activity, and healthy eating; • grants to schools to build or expand capacity at school based health centers where the school based health centers provide support for their public health functions: educating future adult health care consumers on healthy behaviors and on the use of health care; • grants to providers to conduct outreach campaigns to promote family planning among adolescents where the providers support family life education consultation programs for schools and communities as well as community based adolescent pregnancy prevention projects. Outreach educators provide comprehensive family life education that includes information about abstinence and information on preventing sexually transmitted diseases and birth control. Examples of activities include: interactive workshops for youth, educational displays at health fairs for teens, and office hours at teen centers; and • grants to a contractor to develop media campaigns to promote tobacco prevention among children and youth where the contractor develops a statewide marketing campaign for the Partnership for a Tobacco-Free Maine which has a targeted audience of children and youth.

The school health coordinator initiative will serve approximately 5,000 individuals and the adolescent family planning initiative will serve approximately 7,500 individuals.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

The utilization controls are the same for all MaineCare members regardless of the source of funds. The following utilization controls are in use:

1. Primary Care Providers – Under the primary care case management initiative, each MaineCare member has a Primary Care Provider who is responsible for managing (treating or referring out for treatment) the member’s health care. MaineCare members must receive authorization

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8 Approval Date: from their Primary Care Provider for those covered MaineCare services designated as ‘managed services’. For those MaineCare covered services that do not require PCP authorization members may self-refer or seek prior authorization, as is noted below.

2. Prior Authorization – Prior authorization is required for certain MaineCare covered services obtained in-state and all MaineCare covered services provided out-of-state (with the exception of emergency services and services furnished by providers located within 15 miles of the New Hampshire border and 5 miles of Canadian border who are treated as in-state providers). All services requiring prior authorization are reviewed for medical necessity. Prior authorization for services rendered out-of-state is provided only when a member’s continuity of care must be preserved for medical reasons and only after it is determined that the needs of the member cannot be met in the State of Maine.

3. Utilization Review – Ongoing monitoring of health care received by MaineCare members is provided by staff of the Program Integrity Unit within the Bureau of Medical Services. Ongoing sampling is conducted to review the utilization of care and services received by MaineCare members and also to evaluate necessity, quality, quantity and timeliness of services provided to MaineCare members.

4. Member Restriction – Member restriction is an administrative procedure established for MaineCare members with a history of over utilization of benefits. Participants must receive their primary medical care from one (or multiple specified providers). Primary purposes for restricting members to specified provider(s) are: 1) to decrease and control over utilization and/or abuse of covered health care services/benefits and to minimize medically unnecessary and addictive drug usage; 2) to establish a method of monitoring non-emergency health care services for members who have utilized health care services or benefits at a frequency or amount that is not medically necessary; and 3) to assist members through education and referral towards appropriate health care service and benefit use.

5. Utilization Report/Primary Care Physician Incentive Payment Report – Member utilization is also measured through preventive/quality indicators presented in the Utilization Report and Primary Care Physician Incentive Payment Report which are provided to MaineCare primary care providers at least twice a year. The Utilization Report contains 22 performance measures centered on well-child care, utilization of emergency services, potentially avoidable hospitalizations for chronic/serious medical conditions, and other disease prevention

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9 Approval Date: measures. The Primary Care Physician Incentive Payment Report contains additional performance measures focused on preventive indicators. (These reports are described in more detail in Section 7.)

6. DirigoChoice -The contract between the DHHS and Anthem Blue Cross Blue Shield establishes utilization/quality assurance requirements in compliance with CFR 438 for MaineCare members enrolled in DirigoChoice.

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Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1.

Geographic area served by the Plan: Statewide

4.1.2.

Age: Individuals must be under 19 years of age.

4.1.3.

Income: The upper income limit for Title XXI is 200% FPL.

4.1.4.

Resources (including any standards relating to spend downs and disposition of resources):

4.1.5.

Residency (so long as residency requirement is not based on length of time in state): To be eligible for MaineCare, a child must be a resident of the State of Maine.

4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility):

4.1.7.

Access to or coverage under other health coverage: Children must be uninsured to be eligible for Title XXI funded coverage.

4.1.8.

Duration of eligibility: In general, a child who has been determined eligible for MaineCare shall remain eligible for 12 months unless the child attains the age of 19 or is no longer a resident of the State. Eligibility is redetermined prior to the end of each twelve month period. A child may be ineligible for a subsequent 12-month period of eligibility for a specified length of time (as described in section 8.7) for nonpayment of premiums.

4.1.9.

Other standards (identify and describe):

The Bureau of Family Independence MaineCare Eligibility Manual sets forth the eligibility policies for Titles XIX and XXI. Sections 1230 and 9000.02 of the Manual clearly state that

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11 Approval Date: Social Security numbers are not required for children applying for Title XIX and XXI coverage.

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

4.2.1.

These standards do not discriminate on the basis of diagnosis.

4.2.2.

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

4.2.3.

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

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

All administrative processes are designed by the Department of Health and Human Services to be seamless for children applying for MaineCare. As such, all enrollment and eligibility processes are the same for Title XIX and Title XXI, with the only discernable difference being premium billing for those Title XXI children at 151% through 200% FPL.

There is one application and renewal form for families and children who want to apply for MaineCare coverage. The Department of Health and Human Services, Bureau of Family Independence eligibility specialists determine if applicants are eligible for Title XIX or XXI coverage depending on family income.

Eligibility applications may be completed at any of the Department’s regional offices or at home and returned by mail. No interview is necessary.

The Bureau of Family Independence notifies families of their eligibility by mail. Those eligible Title XXI children at 151% through 200% FPL are, in addition to their enrollment cards, mailed monthly premium bills (please see Section 8.2).

A child who has been determined eligible for MaineCare remains eligible for a 12 month enrollment period unless the child attains the age of 19 or is no longer a resident of the State. Eligibility is redetermined prior to the end of each 12 month period. Written notification is sent to each family by the Bureau of Family Independence containing the end date of the child’s 12- month enrollment period and a renewal form to be returned by mail upon

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In summary, MaineCare policy requires eligibility specialists to review all applications, denials, closings, changes in MaineCare Title XIX funded coverage for Title XXI funded coverage and vice versa.

Families are allowed to purchase coverage for a child whose family income at the end of the 12-month enrollment period exceeds 200% of FPL. The purchase of coverage is available for 18 months. The child’s family is responsible for paying the full cost of the coverage, which covers the benefit cost plus an administrative cost not to exceed the maximum allowable under COBRA.

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

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

In order to provide health coverage to as many children as possible within the fiscal constraints of the program budget (as defined in the Balanced Budget Act of 1997), the maximum eligibility level is subject to adjustment by the Commissioner of the Department dependent on the fiscal status of the program. If program expenditures are anticipated to exceed the program budget, the Commissioner shall reduce the maximum eligibility level to the extent necessary to bring the program expenditures within the program budget. If expenditures are expected to fall below the program budget, the Commissioner shall increase the maximum eligibility level to the extent necessary to provide coverage to as many children as possible within the fiscal constraints of the program budget.

Children of higher income may not be covered unless children of lower income are also covered. If the Commissioner has reduced the maximum eligibility level, children of higher income may be disqualified at the end of the twelve month enrollment period, but not during the twelve-month period.

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including a state health benefits plan) are furnished child health assistance under the state child health plan. (Section 2102)(b)(3)(A))

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13 Approval Date: (42CFR 457.350(a)(1) and 457.80(c)(3)) As noted in Section 4.3, the same application and enrollment process is used by all families applying for coverage under MaineCare. A child applying for coverage under MaineCare is first screened by Bureau of Family Independence eligibility specialists for eligibility under Title XIX. Those children deemed ineligible under Title XIX are then screened for eligibility under Title XXI.

Applicants are asked to provide insurance information as part of the application process. Specific questions on the application ask about children in the household who: (1) currently have insurance; (2) have lost health insurance in the last 3 months; and (3) could be added to the State employee health insurance plan. Depending on the answer to these questions, Bureau of Family Independence eligibility specialists will determine if an applicant is eligible for Title XXI funded coverage.

This same process is followed for subsequent eligibility determinations.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

Please see Section 4.4.1 above.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

Please see Section 4.4.1 above.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

Applicants are asked to provide insurance information as part of the application process. Specific questions on the application ask about children in the household who: (1) currently have insurance; (2) have lost health insurance in the last 3 months; and (3) could be added to the State

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14 Approval Date: employee health insurance plan. There is a 3 month waiting period for children who drop employer based coverage. The child may enroll without having to wait 3 months if:

• The employer plan does not pay at least 50% of the cost of the child’s coverage; • The cost of covering the whole family under the employer’s plan is more than 10% of the family income; • The Department determines that good cause exists for dropping the employer based coverage.

In addition, eligibility records are matched against third party liability records to cross check to see if the third party liability records indicate that other insurance is available. A list of Title XXI funded members identified as having insurance is sent to Bureau of Family Independence eligibility specialists to review.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution.

4.4.4.4. If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

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Any eligible child who is American Indian or Alaskan Native is enrolled in MaineCare under Title XIX or Title XXI and treated as any other eligible child, with the exception that the child is not required to pay a premium or other cost sharing.

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16 Approval Date: Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

On an ongoing basis, the Bureau of Medical Services works collaboratively with the Robert Wood Johnson initiative, Covering Kids and Families Campaign to conduct outreach to families. The Campaign’s outreach efforts and goals include:

1. Technical training with staff of community based agencies and health care providers on benefits, eligibility criteria, the application process and program changes to ensure information is disseminated and individuals are enrolled. Each participant is provided with a guide containing the training information. Participants are asked to make a commitment to provide long- term outreach and application assistance to the clients they serve. This model, of reaching potentially eligible individuals through trained personnel with whom they have established relationships, has proven an effective outreach method.

2. Mass media interventions through annual statewide/local media events. Three events are held each year to highlight availability of health care coverage. Events often coincide with national campaigns, such as Cover the Uninsured Week.

3. Targeted outreach to specific constituencies including: Education; Businesses and unions; Social service agencies and municipalities; Faith- based and service organizations; Health care providers and insurers.

4. Distribution of electronic newsletter to interested parties. The newsletter contains information on MaineCare and other health care coverage programs (e.g. DirigoChoice) as well as the overall efforts of the campaign.

5. General training for community organizations such as the Kiwanis, Elks, Lions Clubs, etc. General trainings also provided to statewide organizations such as the Association of Health Care Administrators – Maine, General Assistance Administrators, WIC Directors.

6. Information booths at health fairs, professional conferences, e.g., Maine Pediatric Association meetings.

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7. Grass roots outreach by local coalitions such as attendance at local kindergarten registration events; local promotional events (e.g., providing application assistance booth during school carnival).

The Campaign’s efforts to assist individuals in enrolling include:

1. HelpLine—Maintenance of a statewide toll free HelpLine where trained workers: a.) inform callers of coverage options and assist with application or reenrollment process; b.) provide information about application assistance sites or other appropriate services/programs in the geographical area; c.) serve as resource to hundreds of sites the Campaign has trained to provide application assistance.

2. Expanded Application Capacity—Maintenance and expansion of statewide sites available to provide applications and application assistance (including reenrollment).

The Campaign also gathers information from constituencies, local coalitions, technical trainings, and HelpLine calls to identify problems or barriers families are encountering in accessing or continuing coverage for their children.

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18 Approval Date: Section 6 Coverage Requirements for Children’s Health Insurance (Section 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1 The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

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

6.1.1.1

FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3

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

6.1.2

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

6.1.3

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

6.1.4

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1

Coverage the same as Medicaid State plan 6.1.4.2

Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3

Coverage that either includes the full EPSDT benefit or that the state has extended to the entire

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19 Approval Date: Medicaid population 6.1.4.4

Coverage that includes benchmark coverage plus additional coverage

6.1.4.5

Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7

Other (Describe)

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

6.2.1

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

6.2.2

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

6.2.3

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

Transplants as specified in the MaineCare Benefits Manual, Chapter II, Section 90, Physician Services.

Cosmetic surgery not covered.

6.2.4

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

6.2.5

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

6.2.6

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

. 6.2.7

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

As specified in the MaineCare Benefits Manual, Chapter II, Section 80, Pharmacy

6.2.8

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

6.2.9

Prenatal care and pre-pregnancy family services and supplies

Model Application Template for the State Children’s Health Insurance Program

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20 Approval Date: (Section 2110(a)(9))

6.2.10

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

Certain limits and prior authorization requirements apply.

6.2.11

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

Certain limits and prior authorization requirements apply.

6.2.12

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

Prescribed equipment must be medically necessary.

Prior authorization required for certain items.

6.2.13

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

Prescribed medical supplies must be needed to relieve or control a medical condition.

6.2.14

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

Home health and personal care services will be provided, including part-time or intermittent nursing service provided by a home health agency, home health aid services, physical therapy, occupational therapy or speech-language pathology services, and environmental modifications to the home. Maine has 3 section 1915(c) waiver for the provision of home and community based services where appropriate as an alternative to institutionalization.

6.2.15

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

Includes Nurse Practitioners, Nurse Midwives, Certified Clinical

Model Application Template for the State Children’s Health Insurance Program

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21 Approval Date: Nurse Specialists and Certified Registered Nurse Anesthetists.

6.2.16

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

6.2.17

Dental services (Section 2110(a)(17))

Prior authorization is required for orthodontia and certain other services.

6.2.18

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

Certain limits and prior authorization requirements apply.

6.2.19

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

Certain limits and prior authorization requirements apply.

6.2.20

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

6.2.21

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

6.2.22

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

6.2.23

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

6.2.24

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

Services of chiropractors and podiatrists are covered. Prevention, Health Promotion and Optional Treatment Services (EPSDT), private duty nursing services and genetic testing services are also covered.

Podiatrists’ services are limited to non-routine procedures; treatment of plantar warts, ingrown nails, ulcerations, bursitis, and infections; and minor surgery under local anesthetic. Some routine procedures are covered if there are complications due to foot pathology.

Model Application Template for the State Children’s Health Insurance Program

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22 Approval Date:

Genetic testing services are diagnostic or screening services to determine risk for genetic diseases.

6.2.25

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

6.2.26

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

All transportation to medically necessary services covered by MaineCare is available without prior authorization. Out of state transportation requires prior authorization. Also, travel expenses associated with transportation, such as lodging or meals require prior authorization.

6.2.27

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

Interpreter services are covered for non-English, limited English speaking and /or deaf/hard of hearing individuals.

6.2.28

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

Rural health clinic services and other ambulatory services furnished by a rural health clinic, as well as federally qualified health center services are covered.

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR

6.3.2

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4 Additional Purchase Options. If the state wishes to provide services under the

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23 Approval Date: plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010)

6.4.1

Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1 Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2 The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above.; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3 The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2

Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

Model Application Template for the State Children’s Health Insurance Program

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24 Approval Date:

6.4.2.1 Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a))

6.4.2.2 The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3 The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

Model Application Template for the State Children’s Health Insurance Program

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25 Approval Date: Section 7 Quality and Appropriateness of Care

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

7.1 Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1

Quality standards

Performance measurements developed by the Bureau as part of Utilization Reporting and the Primary Care Physician Incentive Payment program (discussed in detail Section 7.1.2) were modeled on both national (NCQA) standards and standards developed specifically for the State of Maine.

The Bureau of Medical Services has also adopted the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents to assure quality and appropriateness of care with respect to well-baby care, well-child and adolescent care (through age 21) and administration of age appropriate immunizations. The Bureau has developed and distributed a Bright Futures forms that contain age appropriate periodicity schedules for well-child checks and immunizations to providers. These 19 age appropriate forms serve many purposes including, but not limited to:

• Serves as reminder for primary care providers on age appropriate screening services; • May serve as the provider’s medical record, provided it is complete; • Provides MaineCare with information about needed follow-up services that can be provided by MaineCare Member Services.

(Use of these forms is discussed in more detail in Section 7.1.4.)

Additionally, the Bureau has also formed a committee (MaineCare Immunization Sub-Committee) whose charge is to monitor the rate of immunizations for all MaineCare children and to determine appropriate interventions for increasing the rate of immunizations. The committee is comprised of staff from MaineCare Member Services and

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26 Approval Date: representatives from the Bureau of Health Immunization Program and WIC Program. On an annual basis, staff from the Bureau of Health conduct medical record reviews on a sampling of children enrolled in MaineCare to assess immunization rates and report to the CMS GPRA project director on MaineCare’s immunization rate for children from birth to age 2. Information from the sampling is combined with the claims data to create a hybrid rate and determine appropriate interventions, e.g., public service announcements and other forms of advertising stressing the importance of immunizations for all appropriate age groups.

Another group, the Benefits for Members Under 21 Committee, meets periodically and is comprised of staff from the Bureau of Medical Services and Bureau of Health child-related programs such as: WIC, Public Health Nursing, Oral Health, and the Teen and Young Adult Health. The purpose of the group is to coordinate outreach and planning activities for promoting access to services across all programs.

7.1.2

Performance measurement

The Bureau uses two primary means of monitoring and providing feedback to providers regarding performance: a Utilization Report and the Primary Care Physician Incentive Payment report. The Utilization Report is distributed to primary care physicians at least twice a year and contains 22 performance measures centered on well-child care, utilization of emergency services, potentially avoidable hospitalizations for chronic/serious medical conditions, and other disease prevention measures. The report, broken down by specialty, presents a comparison of each primary care physician against other statewide providers across all performance measures. The Primary Care Physician Incentive Payment report contains additional performance measures focused on preventive indicators and is used for purposes of provider education and determining incentive payments.

The Bureau has also developed an incentive program designed to improve health outcomes through management of drug utilization. The Physician Directed Drug Initiative provides incentive payments to providers based on measures of peer performance for certain relevant desired drug outcomes/medical conditions (e.g., increase in percentage of CAHF patients on ACEI); peer performance for medical outcomes related to these medical conditions (e.g., maintain/reduce hospital/ER visits for CAHF patients); and peer performance for medical outcomes across all medical conditions aggregated together (e.g., total hospitalization rates, length of stay, readmission rates/ER rates).

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27 Approval Date: Additionally, in 2001, the Bureau conducted a two-part survey, “Your Voice Counts”, to assess the quality of care for low-income children enrolled in MaineCare. Primary survey goals included: correlation of parents’ perceptions with provider documentation on encounter forms; assessment of members’ perception of needed services and education; and use of aggregate data to update Bright Futures forms. Surveys were sent to 4,200 case heads with MaineCare eligible children between the ages of 3-48 months. A separate survey was developed to ascertain providers’ perceptions of what transpired during well child visits. Survey results were analyzed and linked to Bright Futures assessment forms to determine if parent/guardian opinion on services differed from actual EPSDT information provided on the Bright Futures forms. Overall, it was determined that when Bright Futures forms were used, there was a greater degree of satisfaction with the visit.

The Bureau also routinely monitors complaints and grievances received from members, provider transfer rates, provider caseload size and 24 hour coverage by primary care providers. Complaints and grievances are monitored for trends and required interventions and/or follow-up. Provider transfer rates (members transferring out of a particular practice) and caseload sizes are also monitored on a regular basis to determine whether intervention is required. Each primary care provider is also monitored once a year to ensure that each practice is providing the requisite 24 hour coverage for MaineCare members.

7.1.3

Information strategies

Within 30 days of enrollment, each MaineCare member is sent a mailing containing the informing letter, as required by EPSDT, and information describing covered services, locating providers, available assistance for scheduling visits and transportation, etc. The mailing also contains a postcard (which may be returned postage free) to be completed by those members who require assistance from the Department. Follow-up is provided by Member Services’ staff. Member Services will provide the member with requested assistance and will also provide information on statewide resources available for non- covered services. A Resource Guide is maintained and updated regularly and contains resources available on health and social services in the State, broken down by county. Members are also sent a reminder mailing containing information on when well child visits are due, in accordance with the EPSDT periodic schedule. The reminder mailing also contains information previously sent out with the initial informing letter, i.e., information on locating providers, available assistance for scheduling visits and transportation, etc.

Model Application Template for the State Children’s Health Insurance Program

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28 Approval Date: On an ongoing basis, members and providers are sent periodic educational newsletters. The “MaineCare Managed Care Newsletter” is sent out on a quarterly basis and contains program information/updates for managed care members. The “MaineCare Managed Care Update” is a newsletter sent to providers on a quarterly basis and contains program/clinical information. “Facts and Footnotes” is a newsletter mailed out to all MaineCare providers periodically and contains program/administrative information.

In addition to the postcard used by members, the Bureau has developed a postcard for use by providers. This postcard is used by primary care providers to identify and request needed assistance from the Bureau on behalf of members on their panel. When appropriate, follow-up with the member may be provided by Member Services and, if needed, by Public Health Nurses. For example, a member may be provided with assistance locating transportation to the doctor’s office for well-child checks or in obtaining follow-up treatment recommended by health care providers.

Another informational tool used by the Bureau to educate members is Helpline messages. Members calling Member Services who are placed on hold listen to pre-recorded messages containing information regarding MaineCare benefits and available resources.

The Bureau also provides member education on inappropriate use of the emergency room. On a quarterly basis, the Bureau examines the 5 most prevalent diagnoses for inappropriate emergency room use. These members are contacted to assist with any barriers to care that may exist to accessing care in an appropriate setting (such as transportation). For example, members may not be aware that their primary care provider is available 24 hours or the provider may not have been available and intervention is needed with the provider.

7.1.4

Quality improvement strategies

A primary quality improvement strategy used by the Bureau to ensure access to well-baby/child/adolescent care and immunizations is the required use of a Bright Futures form (BF19) by MaineCare providers. The BF19 form (actually 19 age specific forms) was developed with input from pediatricians and other primary care physicians in the State and based on Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. Each primary care provider participating with MaineCare who has signed an EPSDT Rider to the provider/supplier agreement is required to use the forms when providing well-child visits and is paid an enhanced reimbursement for

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29 Approval Date: use of the form. Each form contains age-appropriate health measures and immunizations and is used for children from birth through age 21.

The BF19 forms are also used by providers and the Bureau to provide members with any needed assistance to comply with treatment plans, e.g., assistance with accessing follow-up treatment or diagnostic testing. The BF19s are reviewed by Department nursing staff on a daily basis for requested follow-up with the member. Forms are then shared with EPSDT staff for actual follow-up with the family. Once follow-up has occurred, notification is sent to the provider.

The Bureau also furnishes providers (as is noted in Section 7.1.2) with information on emergency room visit rates for his/her practice to enable the provider to address the issue of inappropriate use of the emergency room with his/her patients.

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

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

Please see Sections 7.1.1-7.1.4.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

Please see Sections 7.1.1-7.1.4.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

One method used to monitor and enhance treatment of members with chronic/serious medical conditions is the use of the Utilization Report provided to primary care providers. As is noted in Section 7.1.2., the Utilization Report, provided to each primary care provider at least twice a year, contains information on potentially avoidable hospitalizations for particular chronic/serious medical conditions. The information presents a comparison of the particular PCP’s practice against other statewide providers in the same specialty (admission rates per 1000 MaineCare

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30 Approval Date: members per year). The report also contains a listing of the particular MaineCare members on the PCP’s panel currently hospitalized with the identified conditions.

MaineCare managed care members in need of treatment by specialists may access care through referral from the member’s Primary Care Provider for those covered MaineCare services designated as ‘managed’ services. For those MaineCare services that do not require PCP authorization, members may self-refer or seek prior authorization from the Bureau.

Prior authorization is required for certain MaineCare covered services obtained in-state and all MaineCare covered services provided out-of- state (with the exception of emergency services and services furnished by providers located within 15 miles of the New Hampshire border and 5 miles of Canadian border who are treated as in-state providers). Prior authorization for covered services rendered out-of-state is provided only when a member’s continuity of care must be preserved for medical reasons and only after it is determined that the needs of the member cannot be met in the State of Maine.

Another management tool developed and used by the Bureau to monitor and manage MaineCare members with chronic pain is the Pain Management Program. Members receiving 3-5 narcotics from different prescribers or 6+ different narcotics are invited to voluntarily join the program. Under the program, members are matched with one physician responsible for managing all medication use by the member with patient safety as a primary focus

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

Prior authorization of health services are completed in accordance with MaineCare requirements.

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31 Approval Date: Section 8. Cost Sharing and Payment (Section 2103(e))

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

8.1 Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1

YES 8.1.2

NO, skip to question 8.8.

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

8.2.1 Premiums: Families with income from 151% through 200% FPL, pay premiums for MaineCare coverage for children based on a sliding scale applied to gross family income as follows:

• Below 150% FPL - no premium; • 150% to 160% FPL - premiums are $8 per month for the first child and $16 per month for 2 or more children; • 160% to 170% FPL - premiums are $16 per month for the first child and $32 per month for 2 or more children; • 170% to 185% FPL - premiums are $24 per month for the first child and $48 per month for 2 or more children; • 185% to 200% FPL - premiums are $32 per month for the first child and $64 per month for 2 or more children.

8.2.2 Deductibles: Not applicable

8.2.3 Coinsurance or copayments: Coinsurance - Not applicable Copayments - Not applicable

8.2.4 Other: Not applicable

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

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32 Approval Date:

The public is notified through the rule-making process, as provided under the Maine Administrative Procedures Act.

In addition, outreach materials include information informing individuals that, depending on household income, some families may have to pay a premium for their child’s coverage and the dollar amounts of the premiums.

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

8.4.1

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

8.4.2

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

8.4.3

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

8.5 Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

As shown in the following table, the premium is never higher than the equivalent of 3.3 % of family income for those at the lowest end of the FPL range.

Premium as a % of Benefit Cost Monthly Premium Cost* Minimum Monthly Income** Premium as a % of Minimum Income*** No. of Children 1 2 1 2 1 2 1 2 FPL:

150% - 160% 5% 10% $8 $16 $1164 $1562 0.7% 1% 160% - 170% 10% 20% $16 $32 $1250 $1666 1.3% 1.9% 170% - 185% 15% 30% $24 $48 $1319 $1770 1.8 % 2.7% 185% - 200% 20% 40% $32 $64 $1436 $1926 2.2% 3.3%

* Based on an estimated annual benefit cost of $1920 per child or $160 monthly.

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33 Approval Date:

** Minimum monthly income corresponds to 150% (for 150% - 160%), 160% (for 160% - 170%), 170% (for 170% - 185%) and 185% (for 185% - 200%) of 2004 FPL

***The premiums as a % of minimum income will change (lower) when we adjust for the annual FPL increase.

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

As noted in Section 4.4.5, any eligible child who is American Indian or Alaskan Native is enrolled in MaineCare under Title XIX or Title XXI and treated as any other eligible child, with the exception that the child is not required to pay a premium or other cost sharing. On the application form, there is a specific question that asks applicants whether they are American Indian or Alaskan Native and informs them that American Indians and Alaskan Native don’t have to pay premiums. If an applicant checks this box and is enrolled in MaineCare, the Department does not generate premium coupons for the member.

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

Premiums must be paid at the beginning of each month for coverage for that month. When a premium is not paid at the beginning of a month, DHS shall give notice of nonpayment at that time. At the beginning of the 12th month of the 12 month enrollment period, notification will be given if any premiums for the enrollment period have not been paid when due.

There is a grace period for non-payment of premiums. For the first through 11th month of the 12 month enrollment period, the grace period extends through the last day of the 12 month enrollment period. The grace period for payment of the premium due in the 12th month is the 15th of the next month.

There is a month of ineligibility for each month a premium was due, coverage was received, and a premium was not paid. The maximum period of ineligibility is 3 months. The penalty starts in the first month following the end of the enrollment period in which the premium was due. For example, if no premiums are paid for the 12 month enrollment period of January 2002 – December 2002, the child is not eligible for coverage for the months of January – March 2003.

8.7.1 Please provide an assurance that the following disenrollment

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34 Approval Date: protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220)

8.8.2

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5)

8.8.3

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1))

8.8.4

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5))

8.8.5

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of

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35 Approval Date: rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475)

8.8.6

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

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36 Approval Date: Section 9 Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1 Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

See Appendix 9.2.

9.2 Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

See Appendix 9.2.

9.3 Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

See Appendix 9.2.

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

9.3.1

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2

The reduction in the percentage of uninsured children. 9.3.3

The increase in the percentage of children with a usual source of care. 9.3.4

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6

Other child appropriate measurement set. List or describe the set used. 9.3.7

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as:

9.3.7.1

Immunizations 9.3.7.2

Well child care 9.3.7.3

Adolescent well visits 9.3.7.4

Satisfaction with care 9.3.7.5

Mental health

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

37 Approval Date: 9.3.7.6

Dental care 9.3.7.7

Other, please list:

9.3.8

Performance measures for special targeted populations.

9.4 The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

9.5 The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

Information for the annual report comes from the Bureau of Medical Services, Division of Health Care Managements initiatives as outlined in Section 7 of this document. Additionally, the Bureau contracts with the Muskie School of Public Services at the University of Southern Maine to survey new enrollees and disenrollees regarding their use of and satisfaction with MaineCare coverage.

9.6 The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

9.7 The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8 The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1

Section 1902(a)(4)(C) (relating to conflict of interest standards)

9.8.2

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment)

9.8.3

Section 1903(w) (relating to limitations on provider donations and taxes)

9.8.4

Section 1132 (relating to periods within which claims must be filed)

9.9 Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a)

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

38 Approval Date: and (b))

In 1997, the Maine Legislature passed legislation establishing the Maine Commission on Children’s Health Care. The Commission was comprised of state legislators, medical and legal experts, advocates and consumers. The Commission was charged with considering the problem of uninsured children in Maine and reviewing options to increase the number of children who are insured.

Beginning in October 1997, the Commission solicited input regarding providing coverage for uninsured children through a series of public meetings. In January 1998, the Commission presented its report to the Governor and the Legislature, based on their meetings and public testimony. Resulting State Legislation authorized the MaineCare expansion and implementation of a separate program.

On an on-going basis, the Department receives input from the MaineCare Advisory Committee. The Committee meets monthly to review issues regarding MaineCare eligibility, service delivery, and benefits.

All rules regarding eligibility or benefits are proposed and adopted pursuant to the Maine Administrative Procedures Act, which allows for public input via public hearings or submission of written comments.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

A staff member of the Bureau of Medical Services serves as the liaison between MaineCare and Indian Tribes in the State. On a periodic basis, this staff member meets with Health Directors from the various Tribes in order to update them on MaineCare policies and procedures and to address any issues they have regarding MaineCare.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in §457.65 (b) through (d).

The Department’s Bureau of Family Independence issued proposed rules regarding the increased premiums. The notice of rulemaking was published in 5 daily Maine newspapers on July 14, 2004. No public hearing was scheduled; written comments were accepted through August 13, 2004. During the week of September 27, 2004, the Department sent a letter to all current members who are paying a

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

39 Approval Date: premium for title XXI funded coverage notifying them of the premium increase. Effective November 1, 2004, the premium increases will be implemented as members come up for renewal. At that time, they will be notified of the exact amount of their new premium.

9.10 Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140) • Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. SCHIP Budget Plan

Current FFY Budget Budget Increase For Requested SPA

Current B SPA B Incre Federal Fiscal Year

FFY 2005 FFY 2005 FFY 2 State's enhanced FMAP rate

.7542

Benefit Costs

Insurance payments

Managed care

per member/per month rate @ # of eligibles

Fee for Service

$ 31,480,176 $ - $ 31,48 Total Benefit Costs

$ 31,480,176 $ -

$ 31,48 (Offsetting beneficiary cost sharing payments)

$ 783,504 $ -

$ -78 Net Benefit Costs

$ 30,696,672 $

$ 30,69

Administration Costs

Personnel

General administration

$ 1,100,000 $ $ 1,10 Contractors/Brokers

Claims Processing

Outreach/marketing costs

Other: Health Service Initiatives

$ 2,100,000

$ 2,10 Total Administration Costs

$ 3,200,000 $

$ 3,20 10% Administrative Cap

$ 3,410,741

$ 3,41

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

40 Approval Date:

Federal Share

$ 25,564,870 $

$ 25,56 State Share

$ 8,331,802 $

$ 8,33 TOTAL COSTS OF APPROVED SCHIP PLAN

$ 33,896,672 $

$ 33,89

Beneficiary cost-sharing payments have been accounted for and Net Benefit costs are net of the cost-shar

The Source of State Share Funds:_ State General Funds_______________________________________

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

41 Approval Date: Section 10 Annual Reports and Evaluations (Section 2108)

10.1 Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1

The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2

The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3

The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

42 Approval Date: Section 11 Program Integrity (Section 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue to Section 12.

11.1

The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2 The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9)

11.2.1

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents)

11.2.2

Section 1124 (relating to disclosure of ownership and related information)

11.2.3

Section 1126 (relating to disclosure of information about certain convicted individuals)

11.2.4.

Section 1128A (relating to civil monetary penalties)

11.2.5

Section 1128B (relating to criminal penalties for certain additional charges)

11.2.6

Section 1128E (relating to the National health care fraud and abuse data collection program)

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

43 Approval Date: Section 12 Applicant and enrollee protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

The review process for SCHIP eligibility and enrollment matters is identical to the Medicaid review process.

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR 457.1120.

The SCHIP review process for health matters is identical to the Medicaid review process.

Premium Assistance Programs

12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

N/A

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

44 Approval Date: Appendix 9.2

STRATEGIC OBJECTIVES, PERFORMANCE GOALS AND PERFORMANCE MEASURES

STRATEGIC OBJECTIVE PERFORMANCE GOAL PERFORMANCE MEASURE Collaborate with Covering Kids & Families Outreach Campaign to provide technical training to staff of community agencies and health care providers Number of trainings and number of participants Maintain quality of technical training Summary of evaluation comments 1. Conduct an effective outreach program Increase SCHIP participation Number ever enrolled in SCHIP Match children with PCPs Number of enrolled children with PCP Track PCP visits/access Number of visits by age groups 2. Ensure consistent source of health care Decrease emergency room use Number of ER visits Track immunization rate –2 yr olds Number of children with appropriate immunizations at age 2 Number/type EPSDT visits performed Monitor EPSDT visits Number /type preventive screenings performed Track lead screening rates Number of lead screenings performed Track well child visits by age groups Number of well child visits 3. Improve health outcomes Track use of appropriate medications for children with asthma Number of children with appropriate medication Increase member satisfaction Survey results 4. Provide quality care to members hospitalizations Track potentially avoidable hospitalizations Rates of potentially avoidable hospitalizations

1 MAINE TITLE XXI STATE PLAN FACT SHEET

Name of Plan:

MaineCare

Date Plan Submitted:

May 19, 1998 Date Plan Approved:

August 7, 1998 Effective Date:

July 1, 1998 (Title XIX expansion)

August 1, 1998 (Title XXI)

Date Amendment #1 Submitted: January 5, 2000 Date Amendment #1 Approved: March 1, 2001 Date Amendment #1 Effective: October 1, 1999

Date Amendment #2 Submitted: April 5, 2001 Date Amendment #2 Approved: June 6, 2001 Date Amendment #2 Effective: March 30, 2001

Date Amendment #3 Submitted: June 28, 2002 Date Amendment #3 Approved: September 19, 2002

Date Amendment #4 Submitted: January 9, 2003 Date Amendment #4 Approved: April 16, 2003 Date Amendment #4 Effective: July 1, 2002

Date Amendment #5 Submitted: October 6, 2004 Date Amendment #5 Approved: January 5, 2005 Date Amendment #5 Effective: November 1, 2004

Date Amendment #6 Submitted: June 29, 2005 Date Amendment #6 Approved: September 22, 2005 Date Amendment #6 Effective: January 1, 2005

Background

• The Maine Children’s Health Insurance Program (CHIP) expanded coverage to children through age 18 in families with incomes up to and including 185 percent of the Federal poverty level (FPL) using a combination of a Medicaid expansion and a separate child health program. The Medicaid expansion covers children aged 1 through 18 in families with income up to and including 150 percent of the FPL; the separate child health program covers children in families with income above 150 percent of the FPL up to and 185 percent of the FPL. The first amendment to Maine’s CHIP state plan increased eligibility up to and including 200 percent of the FPL.

2 • Maine’s Medicaid program covers children from birth through 12 months with family income up to and including 185 percent of the FPL, children aged 1 through 5 in families with income up to and including 133 percent of the FPL, and children aged 6 through 18 in families with income up to and including 125 percent of the FPL.

Amendments

• On January 5, 2000, Maine submitted a state plan amendment to further expand the State’s separate child health program to cover children from birth through age 18 in families with incomes above 185 percent up to and including 200 percent of the FPL. The amendment also removes cost sharing for American Indian and Alaska Native children.

• Maine submitted its second amendment on April 5, 2001, to expand the benefit package provided under the State’s title XXI program by adding hospice services.

• Maine submitted its third amendment on June 28, 2002. This amendment updates and amends the CHIP state plan to indicate the State's compliance with the final CHIP regulations. This amendment also extends Maine’s continuous eligibility period from 6 months to 12 months.

• Maine submitted its fourth amendment on January 9, 2003. This amendment implements health services initiatives (HSI) under the State’s 10 percent administrative cap.

The State’s health services initiatives are activities sponsored by the State’s Bureau of Health under the Partnership for a Tobacco-Free Maine. Specific health services initiatives may include the following:

o Grants to providers to promote health education in schools implementing a school health program that incorporates guidelines for tobacco use, physical activity, and healthy eating and educates on the use of health care. o Grants for conducting outreach campaigns to promote community based pregnancy prevention projects and to promote family planning among adolescents where the providers support family life education programs for schools and communities, including education about abstinence and information on preventing sexually transmitted diseases and birth control. o Grants for media health campaign directed at discouraging children and adolescents from purchasing tobacco products.

• Maine submitted its fifth amendment on October 6, 2004. This amendment increases premiums for children living in families with income above 150 percent up to and including 200 percent of the FPL (separate child health program).

3

• Maine submitted its sixth amendment on June 29, 2005. This amendment adds DirigoChoice, a managed care entity, as a service delivery option for the state’s title XXI program.

Children Covered Under the Program

• The State reported that 30,947children were ever enrolled in CHIP in Federal fiscal year (FFY) 2008.

Administration

• Maine’s Department of Health and Human Services (DHHS) oversees the administration of the MaineCare program. The MaineCare program contains both title XIX and title XXI programs and both are administered in the same manner. Three Bureaus within DHHS share functional responsibility for the title XXI program: the Office of MaineCare Services (OMS) has primary responsibility for administration and oversight; the Office of Integrated Access and Support (OIAS) determines eligibility; and the Maine Center For Disease Control (Maine CDC) oversees the EPSDT, HSI, and immunization programs and conducts outreach and education activities.

Health Care Delivery System

• MaineCare primary care case management initiative is operational in all 16 counties. MaineCare children covered under title XXI funding access services through primary care case management.

• MaineCare members may voluntarily enroll in DirigoChoice, a managed care entity, if they work for a DirigoChoice eligible business that offers the DirigoChoice plan to its employees and they meet the requirements of an eligible employee. MaineCare members who are dependents of DirigoChoice members may also enroll in DirigoChoice.

• MaineCare members not participating in primary care case management or the DirigoChoice initiative can access services through the fee-for-service system.

Benefit Package

• The current Medicaid health benefit package is provided for both the Medicaid expansion and the separate child health program.

4 Cost Sharing

• Maine’s separate child health program has a sliding scale for premiums for children with family incomes above 150 percent up to and including 200 percent of the FPL according to the following schedule:

o Above 150 up to and including 160 percent FPL: premiums are $8 per month for the first child and $16 per month for two or more children. o Above 160 up to and including 170 percent FPL: premiums are $16 per month for the first child and $32 per month for two or more children. o Above 170 up to and including 185 percent FPL: premiums are $24 per month for the first child and $48 per month for two or more children. o Above 185 up to and including 200 percent FPL: premiums are $32 per month for the first child and $64 per month for two or more children.

Coordination between Separate Child Health Program and Medicaid

• Applicants for both programs use the same simplified eligibility form and enrollment process, which is conducted by the Office of MaineCare Services (OMS). Those determined to be Medicaid-eligible are enrolled in Medicaid. Children enrolled under title XXI criteria will be given distinct eligibility codes in order to track coverage under both programs.

Crowd-Out Strategy

• The joint application requests information about current and prior insurance coverage for the most recent 3-month period. If applicants have lost coverage for reasons related to the availability of CHIP, eligibility for the separate child health program will be denied. Children who lost coverage for reasons unrelated to CHIP will remain eligible. If the coverage termination complies with the following guidelines the children will be eligible for the separate child health program:

o The cost of the employee’s share of family coverage exceeds 10 percent of family income. o The employer plan does not pay at least 50 percent of the cost of the child’s coverage. o The Department determines that good cause exists for dropping the employer-based coverage.

Outreach Activities

5

• The Department has aired television and radio public service announcements, distributed posters, and developed newsletter articles for inclusion in publications by community and professional organizations.

• The Office of MaineCare Services (OMS) works collaboratively with the Robert Wood Johnson initiative, Covering Kids and Families Campaign to conduct outreach to families.

• Each year the Department of Health and Human Services, in collaboration with the Department of Education, sends applications to each school to distribute to students during the first week of school.

• Ongoing outreach efforts are also conducted by MaineCare Member Services to assist members enroll in the primary care case management benefit within MaineCare.

Financial Information

Total FFY 2009 SCHIP Allotment: $ 39,271,706 FFY 2007 Enhanced Federal Matching Rate: 75.09%

Date Last Updated: July 28, 2009

_____________________________________________________________________________

Table of Contents

State/Territory Name: Maine

State Plan Amendment (SPA) #: ME-13-0021

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

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

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

7500 Security Boulevard, Mail Stop: 52-01-16 . \ Mi &

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

Children and Adults Health Programs Group

OCT 16 2013

Ms. Amy Dix

Program Manager, CHIP MaineCare Services

11 State House Station Augusta, ME 04333

Dear Ms. Dix:

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers ME-13-0021 and ME-13-0022, submitted on September 13, 2013, and SPA number ME-13-033, submitted on October 8, 2013, all of which are related to Modified

Adjusted Gross Income (MAGI) Eligiblity, have been approved with an effective date of January 1, 2014.

MAGI Eligiblity & Methods:

SPA number ME-13-0021, provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Age and Income Sections 4.1.2 and 4.1.3 of the current CHIP state plan.

Title XXI Medicaid Expansion:

SPA number ME-13-033 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its Title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached and should be incorporated into a new section 4.0 in the state’s approved CHIP state plan.

Establish 2101(f) Group: .

SPA number ME-13-0022 provides coverage in a separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached and should be incorporated within a separate subsection under Section 4.1 of Maine’s approved CHIP state plan.

Your Title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Page 2 — Ms. Amy Dix

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

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

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region I, Division of Medicaid and Children’s Health Operations. Mr. McGreal’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations JFK Federal Building

15 Sudbury Street, Room 2325

Boston, MA 02203

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

Sincerely,

Eliot Fishman Director

Enclosures cc: Richard McGreal, ARA, CMS Region I

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility ME.0323.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Maine State Funds: $ Federal Funds: $ Submitted By: Reinhold Bansmer Last Revision Date: Oct 10, 2013 Submit Date: Sep 13, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. ME-13-0021 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation CS7 2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320; CS15 2102(b)(1)(B)(v) of th Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:62 out of 2000 SPA changes to ensure compliance with the Affordable Care Act. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/10/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/10/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

ccmMs. CHIP Eligibility

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

C87

Separate Child Health Insurance Prog Eligibility - Targeted Low-Income ¢

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

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

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

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

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL) + ilo 1 191 208 xX + i 19 157 208

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

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities? | No

PRA Disclosure Statement

SPA # ME-13-0021 Approval ate, OCT { 6 2013 Effective Date: January 1, 2014

Page | of 2

coms. CHIP Eligibility

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

V.20130709

OCT 16 2013

SPA # ME-13-0021 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

CccomMs. CHIP Eligibility

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

Separate Child Health In MAGI-Based Income M

C815

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

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

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

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

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: @ The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. C The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: (FJ Include a prorated portion of the reasonably predictable increase in future income and/or family size. (7) Account for a reasonably predictable decrease in future income and/or family size.

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

Household income includes actually available cash support. exceeding nominal amounts. provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent.

0

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

An attachment is submitted.

PRA Difgigs: tatement

SPA # ME-13-0021 Approval Date: Effective Date: Janary 1, 2014 Page | of 2

cmMs. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB contro! number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850.

SPA # ME-13-0021 Approval Date: 1 6 2013 Effective Date: Janary 1, 2014

Page 2 of 2

ccmMs CHIP Eligibility

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

Eligibility for Medi

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

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

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) 1 6 140 157 x 6 19 132 157 4

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

SPA # ME 13-033 Approval Date: OCT 1 6 2013 Effective Date: January 1, 2014 Page 1 of 1

coms. CHIP Eligibility

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

CS14

Child Health Insurance P ce Se = Result of the Elimination of Income Disregards

Eligibility - Children

sa

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

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

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

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

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

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

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

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

% FPL

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

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

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

SPA # ME- 13-0022 Approval pateOeT 1 6 2013 Effective Date: January 1, 2014

Page | of 2

coms CHIP Eligibility

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. C No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

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

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

OCT 16 201

SPA # ME- 13-0022 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Maine

State Plan Amendment (SPA) #: ME-13-0022

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

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

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

7500 Security Boulevard, Mail Stop: 52-01-16 . \ Mi &

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

Children and Adults Health Programs Group

OCT 16 2013

Ms. Amy Dix

Program Manager, CHIP MaineCare Services

11 State House Station Augusta, ME 04333

Dear Ms. Dix:

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers ME-13-0021 and ME-13-0022, submitted on September 13, 2013, and SPA number ME-13-033, submitted on October 8, 2013, all of which are related to Modified

Adjusted Gross Income (MAGI) Eligiblity, have been approved with an effective date of January 1, 2014.

MAGI Eligiblity & Methods:

SPA number ME-13-0021, provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Age and Income Sections 4.1.2 and 4.1.3 of the current CHIP state plan.

Title XXI Medicaid Expansion:

SPA number ME-13-033 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its Title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached and should be incorporated into a new section 4.0 in the state’s approved CHIP state plan.

Establish 2101(f) Group: .

SPA number ME-13-0022 provides coverage in a separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached and should be incorporated within a separate subsection under Section 4.1 of Maine’s approved CHIP state plan.

Your Title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Page 2 — Ms. Amy Dix

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

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

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region I, Division of Medicaid and Children’s Health Operations. Mr. McGreal’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations JFK Federal Building

15 Sudbury Street, Room 2325

Boston, MA 02203

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

Sincerely,

Eliot Fishman Director

Enclosures cc: Richard McGreal, ARA, CMS Region I

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility ME.0324.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Maine State Funds: $ Federal Funds: $ Submitted By: Reinhold Bansmer Last Revision Date: Oct 10, 2013 Submit Date: Sep 13, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. ME-13-0022 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:62 out of 2000 SPA changes to ensure compliance with the Affordable Care Act. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/09/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/09/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

ccmMs. CHIP Eligibility

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

C87

Separate Child Health Insurance Prog Eligibility - Targeted Low-Income ¢

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

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

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

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

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL) + ilo 1 191 208 xX + i 19 157 208

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

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities? | No

PRA Disclosure Statement

SPA # ME-13-0021 Approval ate, OCT { 6 2013 Effective Date: January 1, 2014

Page | of 2

coms. CHIP Eligibility

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

V.20130709

OCT 16 2013

SPA # ME-13-0021 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

CccomMs. CHIP Eligibility

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

Separate Child Health In MAGI-Based Income M

C815

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

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

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

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

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: @ The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. C The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: (FJ Include a prorated portion of the reasonably predictable increase in future income and/or family size. (7) Account for a reasonably predictable decrease in future income and/or family size.

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

Household income includes actually available cash support. exceeding nominal amounts. provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent.

0

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

An attachment is submitted.

PRA Difgigs: tatement

SPA # ME-13-0021 Approval Date: Effective Date: Janary 1, 2014 Page | of 2

cmMs. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB contro! number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850.

SPA # ME-13-0021 Approval Date: 1 6 2013 Effective Date: Janary 1, 2014

Page 2 of 2

ccmMs CHIP Eligibility

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

Eligibility for Medi

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

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

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) 1 6 140 157 x 6 19 132 157 4

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

SPA # ME 13-033 Approval Date: OCT 1 6 2013 Effective Date: January 1, 2014 Page 1 of 1

coms. CHIP Eligibility

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

CS14

Child Health Insurance P ce Se = Result of the Elimination of Income Disregards

Eligibility - Children

sa

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

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

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

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

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

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

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

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

% FPL

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

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

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

SPA # ME- 13-0022 Approval pateOeT 1 6 2013 Effective Date: January 1, 2014

Page | of 2

coms CHIP Eligibility

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. C No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

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

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

OCT 16 201

SPA # ME- 13-0022 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Maine

State Plan Amendment (SPA) #: ME-13-0024

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

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

DEPARTMENT OF HEALTH & HUMAN SERVICES

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

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

Children and Adults Health Programs Group

Ms. Amy Dix

Program Manager, CHIP MaineCare Services

11 State House Station Augusta, ME 04333

Dear Ms. Dix:

DEC 1 1 2013

Iam pleased to inform you that your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number ME-13-0024, submitted on September 13, 2013, related to Modified Adjusted Gross Income (MAGI) Eligibility, has been approved with an effective date of January 1, 2014.

NON-Financial Eligibility:

SPA number ME-13-0024 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; substitution of coverage; non-payment of premiums, and continuous eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of Maine’s current state plan as laid out below:

New State Plan Page

Impact on Current State Plan

CS17: Non-Financial Eligibility - Residency

Section 4.1.5

CS18: Non-Financial Eligibility - Citizenship

Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security Number

Section 4.1.9.1

CS20: Non-Financial Eligibility —- Substitution of Section 4.4.4

Coverage

CS21: Non-Payment of Premiums Section 8.7 Section 4.1.8

CS27: General Eligibility - Continuous Eligibility

Your Title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Page 2 — Ms. Amy Dix

Facsimile: (410) 786-5882 E-mail: Martin.Burian@cms.hhs.gov

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

Eliot Fishman Director

Enclosures ce: Richard McGreal, ARA, CMS Region I

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility ME.0326.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Maine State Funds: $ Federal Funds: $ Submitted By: Reinhold Bansmer Last Revision Date: Nov 27, 2013 Submit Date: Sep 13, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. ME-13-0024 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation CS17 42 CFR 457.320; CS18 Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:62 out of 2000 SPA changes to ensure compliance with the Affordable Care Act. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 08/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

42 CFR 457.320

Residency

Expiration dat

OMB Control Number: 0938-1148

+ 10/31/2014

A child is considered to be a resident of the state under the following conditions:

@

1. Intends to reside in the state, including without a fixed address, or

[mA non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

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

|

[Ml] A child who is a ward of the state regardless of where the child lives, or

A child physically located in the state when there is a dispute with one or more states as to the child's actual cy residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions:

[ml] A non-institutionalized pregnant woman who is living in the state and: 2. Entered with a job commitment or seeking employment, whether or not currently employed. care homes, by an agency of the state, or

individual established residency in the state prior to entering the institution, or

actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

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

A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed.

An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

1, Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or

fal An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010. including foster HH An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the

im A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's

the individual

state of

SPA #ME-13-0024

Approval ony EC Effective Date: January 1, 2014

Page | of 2

coms. CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. 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 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

DEC 1 1 2013

SPA #ME-13-0024 Approval Date:, Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148

Expiration date: 10/31/2014

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[mi] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation

Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the Yes verification process.

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date Yes earlier than the date the notice is received by the individual.

The date benefits are furnished is: C The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

(@ Other date, as described:

first day of application month

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Yes in the United States, as provided in Section 2107(e€)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). _

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program.

Del 1 1 2019

SPA #ME-13-0024 Approval Date:

Effective Dateplanuanyt 2014

ccmMs CHIP Eligibility

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

No

rl An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

{l) An individual is considered to be lawfully present in the United States if he or she is: 1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

3. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. A non-citizen who belongs to one of the following classes: (i) Granted temporary resident status in accordance with 8 U.S.C.1160 or 1255a, respectively;

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231,or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 1s a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)).

DEC 1 1 2013

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coms CHIP Eligibility

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not

be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number: The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

DEC 1 1 2013

SPA #ME-13-0024 Approval Date: Effective Dateplarwiany f 2014

CHIP Eligibility

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

42 CFR 457.340(b)

Social Security Number As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as

determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or

Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

ry] The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[mM] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the

Fa individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their 0 SSN.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

DEC 1 1 2013 SPA #ME-13-0024

Approval Date: Effective Date: January 1, 2014

Page | of 1

CHIP Eligibility

OMB Control Number: 0938-1148

Ex

10/31/2014

457.310(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1)(C) of the SSA

Substitution of Coverage

[@] Substitution of coverage prevention strategy:

wa The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

Name of policy

Description

Request for insurance information

Applicants are asked to provide insurance information as part of the application process. Specific questions on the application ask about children in the household who: 1) currently have insurance; 2) have lost health insurance in the last 3 months; and 3) could be added to the State Employee Health Insurance Plan. If the child already receives health insurance coverage, CHIP coverage will be denied. If it is determined that a child drops employer-based coverage in order to receive coverage through CHIP, a 3-month waiting period for CHIP coverage will be assessed for the child. If it is determined that a child is eligible for coverage through the State Employee Health Insurance Plan, CHIP coverage will be denied. The child may enroll without having to wait in accordance with the exemptions listed below.

This policy is applied to all applicants; there are no other thresholds.

“| Verification of third-party coverage

Eligibility records are matched against OMS Third- Party Liability unit records to cross-check to see if their records indicate that other insurance is available for a CHIP applicant/member. A list of Title XXI- funded members identified as having insurance is sent by the OMS Third-Party Liability Unit to the Office for Family Independence eligibility specialists for review.

If it is determined that a child is enrolled in another health insurance plan, the child's CHIP coverage will be denied or terminated unless the child meets any of the exceptions listed below.

This policy is applied to all applicants/members; there |

are no other thresholds.

How long is the waiting period?

A waiting period during which an individual is ineligible due to having dropped group health coverage.

SPA #ME-13-0024 Approval pet { i 2013

Effective Date: January 1, 2014

Page 1 of 2

coms. CHIP Eligibility

(C One month C Two months @ 90 days

C Other

[i] The state allows exemptions from the waiting period for the following reasons:

rl The premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of household income.

The child’s parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP {m] through the Marketplace because the ESI in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B—2(c)(3)(v).

[i] The cost of family coverage that includes the child exceeded 9.5 percent of the household income.

im The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan.

i A change in employment, including involuntary separation, resulted in the child’s loss of employer-sponsored insurance (other than through full payment of the premium by the parent under COBRA).

[m] The child has special health care needs.

{M] The child lost coverage due to the death or divorce of a parent.

Does the state allow other exemptions in addition to those listed above? |No

(1 If the state covers pregnant women, the waiting period does not apply to pregnant women.

If the state elects to offer dental only supplemental coverage, the following assurances apply:

The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as oO 8 pply g) PP 8 provided in section 2110(b)(5) of the SSA.

C The waiting period does not apply to children eligible for dental only supplemental coverage.

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

V.20130718

DEC 1 1 2013

SPA #ME-13-0024 Approval Date: Effective Date: January 1, 2014 , Page 2 of 2

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

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? Yes

Please describe the lock-out period:

Premiums are due on the first day of every month. Children are enrolled in CHIP for a full 12 month enrollment period with no interruption in coverage regardless of whether the family is current on their child’s premium payment(s). During the subsequent enrollment period, families are informed that unpaid premiums from the previous enrollment period that have not been received by the state must be paid, and that if the state does not receive these payments, the child will be subject to a period ineligibility. The period of ineligibility will be lifted immediately after payment has been received by the agency. Regardless of whether payment has been received in full by the state for past due premiums, the ineligibility period will not exceed 90 days.

What is the length of the time premium lock-out period? Select a length of time:

C One month

C Two months

@ 90 days

C Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? Yes

[-] Individual's income decreased to a level where no premium is required or within Medicaid standards (7] Other financial hardship Other

Describe

mail delay

illness of child's responsible relative

+ | unanticipated emergency beyond the control of the responsible relative

The state assures that:

DEC 1 1 2013

SPA #ME-13-0024 Approval Date:, Effective Dateplanuany ft 2014

CHIP Eligibility

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3); and

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

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

V.20130709

DEC 1 1 2013

SPA #ME-13-0024 Approval Date:. Effective Dateplanuany f2014

Cems CHIP Eligibility

OMB Control Number: 0938-1148

Expiration date: 10/31/2014 C827

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier.

The CHIP Agency elects to provide continuous eligibility to children under this provision. | Yes

@ For children up to age 19

C For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[W] Atthe end ofthe |12 | months continuous eligibility period.

Exceptions to the continuous eligibility period: [BJ The child attains the age specified by the state Agency or age 19. [Hi] The child or child's representative requests voluntary disenrollment. [il] The child is no longer a resident of the state.

a The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[i] The child dies.

{] There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

(CJ Other

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

V.20130717

SPA #ME-13-0024 Approval Date:, DEC { { 2013 Effective Date: January 1, 2014 Page | of |

_____________________________________________________________________________

Table of Contents

State/Territory Name: Maine

State Plan Amendment (SPA) #: ME-13-0033

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

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

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

7500 Security Boulevard, Mail Stop: 52-01-16 . \ Mi &

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

Children and Adults Health Programs Group

OCT 16 2013

Ms. Amy Dix

Program Manager, CHIP MaineCare Services

11 State House Station Augusta, ME 04333

Dear Ms. Dix:

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers ME-13-0021 and ME-13-0022, submitted on September 13, 2013, and SPA number ME-13-033, submitted on October 8, 2013, all of which are related to Modified

Adjusted Gross Income (MAGI) Eligiblity, have been approved with an effective date of January 1, 2014.

MAGI Eligiblity & Methods:

SPA number ME-13-0021, provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Age and Income Sections 4.1.2 and 4.1.3 of the current CHIP state plan.

Title XXI Medicaid Expansion:

SPA number ME-13-033 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its Title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached and should be incorporated into a new section 4.0 in the state’s approved CHIP state plan.

Establish 2101(f) Group: .

SPA number ME-13-0022 provides coverage in a separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached and should be incorporated within a separate subsection under Section 4.1 of Maine’s approved CHIP state plan.

Your Title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Page 2 — Ms. Amy Dix

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

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

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. Richard McGreal, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region I, Division of Medicaid and Children’s Health Operations. Mr. McGreal’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations JFK Federal Building

15 Sudbury Street, Room 2325

Boston, MA 02203

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

Sincerely,

Eliot Fishman Director

Enclosures cc: Richard McGreal, ARA, CMS Region I

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility ME.0415.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Maine State Funds: $ Federal Funds: $ Submitted By: Reinhold Bansmer Last Revision Date: Oct 10, 2013 Submit Date: Oct 8, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. ME-13-033 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:61 out of 2000 SPA changes to ensure compliance with the Affordable Care Act Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/09/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/09/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

ccmMs. CHIP Eligibility

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

C87

Separate Child Health Insurance Prog Eligibility - Targeted Low-Income ¢

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

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

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

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

Statewide Income Standards

Begin with lowest age range first.

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

From Age To Age Above (% FPL) Up to & including (% FPL) + ilo 1 191 208 xX + i 19 157 208

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

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities? | No

PRA Disclosure Statement

SPA # ME-13-0021 Approval ate, OCT { 6 2013 Effective Date: January 1, 2014

Page | of 2

coms. CHIP Eligibility

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

V.20130709

OCT 16 2013

SPA # ME-13-0021 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

CccomMs. CHIP Eligibility

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

Separate Child Health In MAGI-Based Income M

C815

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

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

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

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

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: @ The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. C The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: (FJ Include a prorated portion of the reasonably predictable increase in future income and/or family size. (7) Account for a reasonably predictable decrease in future income and/or family size.

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

Household income includes actually available cash support. exceeding nominal amounts. provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent.

0

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

An attachment is submitted.

PRA Difgigs: tatement

SPA # ME-13-0021 Approval Date: Effective Date: Janary 1, 2014 Page | of 2

cmMs. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB contro! number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850.

SPA # ME-13-0021 Approval Date: 1 6 2013 Effective Date: Janary 1, 2014

Page 2 of 2

ccmMs CHIP Eligibility

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

Eligibility for Medi

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

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

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) 1 6 140 157 x 6 19 132 157 4

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

SPA # ME 13-033 Approval Date: OCT 1 6 2013 Effective Date: January 1, 2014 Page 1 of 1

coms. CHIP Eligibility

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

CS14

Child Health Insurance P ce Se = Result of the Elimination of Income Disregards

Eligibility - Children

sa

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

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

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

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

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

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

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

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

% FPL

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

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

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

SPA # ME- 13-0022 Approval pateOeT 1 6 2013 Effective Date: January 1, 2014

Page | of 2

coms CHIP Eligibility

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. C No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

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

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

OCT 16 201

SPA # ME- 13-0022 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Maine State Plan Amendment (SPA) #: ME-17-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Page 3) Approved SPA Pages The complete title XXI state plan for Maine consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 52-01-16 Baltimore, MD 21244-7850 GENTER FOR MEO|CÀ|O & CHtp STRV|CIS and Ä JAN 2'5 2018 Stefanie Nadeau State Medicaid Director Office of MaineCare Services Maine Department of Health and Human Services 242 State Street I 1 State House Station Augusta, Maine 04333-001 1 Dear Ms. Nadeau: I am witing to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) number ME-17-0003, submitted on December 5,2017 , wiTh an effective date of July l, 2017. This SPA allows CHIP eligibility for all children with access to public employee coverage on the basis of a family member's employment who are otherwise eligible targeted low-income children as defined at 42 CFP* 457 .310, provided that the child's household income meets the same income standards as those applied to targeted low-income children under the CHIP state plan. The state will provide this coverage under the hardship exception to the exclusion of employees of a public agency of a state, in accordance with section 21 l0(bX6XC) ofthe Social Security Act. The SPA ME-17-0003 supersedes the curent information on dependents ofpublic employees in the CHIP state plan. In addition, the SPA adds an exception to the state's 90-day waiting period for a period ofone year from the approval date ofthis SPA for children of state employees to emoll in CHIP. As such, this SPA supersedes the current information on waiting period exceptions in the current CHIP state plan and on page CS20. Your title XXI project officer is Ms. Mary (Tess) Hines. She is available to answer questions conceming this amendment and other CHIP related issues. Ms. Hines' contact information is: Cente¡s for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop 52-05-05 Baltimore, MD 21244-1850 Telephone: (410) 786-0435 E-mail : Mary.[]ineslli)cms.hhs.sov

Offlrcial communications regarding program matters should be sent simultaneously to Ms. Hines and to Mr. Richard McGreal, Associate Regional Administrator (ARA) in our Boston Regional Office. Mr. McGreal's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations JFK Federal Building 15 New Sudbury St, Room 2325 Boston, MA 02203-0003 Ifyou have additional questions, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs, at (410) 786-0721. We look forward to continuing to work with you and your staffon your program. Sincerely, A4t¿ Director cc: Mr. Richard McGreal, ARA, CMS Region I, Boston / Anne Marie Costello /

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Summary

Children's Health Insurance Program Eligibility

——

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Maine

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |ME-17-0003 |

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

Proposed Effective Date

(nm de/ yyy)

Federal Statute/ Regulation Citation

[Sec 2110(b)(2)(B) and (b)(6) of the SSA

Federal Budget Impact

¥ This SPA has a budget impact. Total budget impact:

State Funds: $

Federal Funds: $ Please attach a revised CHIP budget.

Document

Please provide a short description of this support

document:

Character Count:61 out of 2000 Document used to calculate budget impact for this population.

Uploaded Document Name: Date Uploaded: LD390_CHIPForStateEEs.xlsx |

Download

Please provide a short description of this support

document:

Character Count: 83 out of 2000

Additional budget document requested that included PMPM and anticipated enrollment.

Uploaded Document Name:

Date Uploaded: CHIP_SPA StateEEs xlsx

Download

Please provide a short description of this support

document:

Character Count:17 out of 2000 Hardship analysis

Uploaded Document Name:

Date Uploaded: Hardship Analysis 2007-2017 rev 2.5 xlsx Download

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count:55 out of 2000

fllows CHIP eligibility to children of state employees.

Signature of State Agency Official

Submitted By: Reinhold Bansmer

Last Revision Jan 23, 2018 Date:

Submit Date: Dec 5, 2017

BACK CONTINUE

ffiF* CHIP Eligibitity State OMB CoÍtrcl Number: 0938-1 148 Transmittal Number: ME - 17 - 0003 PRA Disclosure Statement According to the Papcrwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid oMB co rol number. The vâlid oMB çonÍol number for this information collection is093E-1148. The time required to cómilete tltis information collection is estimated to average 50 hours per response, inctuding the time to review instructions, searõh existing data resoùrces, gâthor the data needed, and complete and review the information collection. Ifyou have comments conceming the accumcy of the tim€ estimale(s) or suggestions for improving this form, please write to: cMs, 7500 Sccurity Boulevard, Attn: pRA Reports Clearance Ofï¡ce¡, Mail Stop C4-26-05, Baltinrore, Marytand 21244-1850. Effect¡ve Date: July 1,2017 Page I of 2 Sec. 2l l0(bX2XB) and (bX6) ofthe SS1\ Childr€n Who Hâve Accosr ao Public Employee Coverage - Other\a¡se eligible targeted low-income children who have acc€ss to public employee coverage on tlte basis ofa family membe/s employment, I The CHIP Agency operâtes this covered group in accordance with the following provisions: Select one ofthc following conditions as described in Section 2l lo(bxir) ofthe Social Secùrity Act: Q Maintenanòe ofagency contributiorì as provided in 2ll0(bX6XB) ofthe SSA. (Ô Hardship criteria as provided in section 2110(bX6XC) ofrhe Soc¡al Security Act. Coverage undcr this option is ext€nded to ohildren whose household income is: Select one of the options for the income standard whon compared to Targeted Low Income Children O The same âs the standards for TargÊted Low-Income Chi¡dren O Lower than the income standards for T[r.geted Low-lncome Children lnd¡aate whelhe¡ coverage under this option is extended to all children who have access to publ¡o employee coverage. or only certain children: (ò All children who have access to public employ€e coverag€ C Ce¡tain children who have aocess to public employee coverage: El Attãch methodology the state hâs used to calculate financial hardship. r-z The state prov¡des assttranc€ that the state will, on an ãnnùal basis, recalculate the financial stalus to detelmine ifthe E hardship condition continues to be met. ,-¡ Children who are eligible for public employe€ health benefits coverage who are not described above are excluded from Ú eligibility under the [lan. f1 Children cons¡dered to hâye acoess to public employee coverage, and therefore not excluded fiom CHIP through this option, " otherw¡se meet the defih¡tion oftargetêd lorv-inçome child prov¡ded ât 42 CFR 457.310, sPA# rvrE-'17-0003 Approval Date: l¡t'l 2 ¡ Ifif

CHIP Etigibility v 20160722 Efeclive Datet July 1 , 2017 Pøge 2 of 2 sPA# t\4E-17-0003 Approval Date: JAN 2 E 20fs

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Maine ME-20-0007

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adults Health Programs Group October 18, 2021 Michelle Probert Director, Office of MaineCare Services State of Maine, Department of Health and Human Services 221 State Street Augusta, ME 04333 Dear Ms. Probert: Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) ME-20-0007, submitted on December 23, 2020, with additional information submitted on October 15, 2021, has been approved. The SPA has an effective date of October 1, 2020. Maine’s SPA ME-20-0007 implements a health services initiative (HSI) to provide lead abatement services in the homes of low-income children. In addition, this SPA restores the state’s current tobacco use prevention HSI, which is a statewide marketing campaign to promote tobacco prevention among children and youth. Section 2105(a)(l)(D)(ii) of the Social Security Act (the Act) and 42 CFR §457.10 authorize use of title XXI administrative funding for expenditures for HSIs under the plan for improving the health of children, including targeted low-income children and other low-income children. Consistent with section 2105(c)(6)(B) of the Act and 42 CFR §457.626, title XXI funds used to support an HSI cannot supplant Medicaid or other sources of federal funding. The state shall ensure that the remaining title XXI administrative funding, within the state's 10 percent limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of these HSIs to the administration of the CHIP program. The state shall report annually to CMS the expenditures funded by the HSIs for each federal fiscal year. The state shall also report at a minimum quarterly to CMS any metrics regarding the implementation of the lead abatement HSI as agreed to by the state and CMS. Your title XXI project officer is Tess Hines. Tess is available to answer questions concerning this amendment and other CHIP-related issues. Tess’s contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-0435 E-mail: Mary.Hines@cms.hhs.gov

Page 2 — Ms. Michelle Probert

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

Sincerely,

/Signed by Amy Lutzky/

Amy Lutzky Deputy Director

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

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

State/Territory:_____Maine_________________________________________________

(Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))_______________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

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

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

Name: Jennifer Patterson Position/Title: Director of Policy Name: David Jorgenson Position/Title: Director of Data Analytics Name: Lea Studholme Position/Title: Senior MaineCare Program Manager Name: Kristin Merrill Position/Title: State Plan Manager Name: Dean Bugaj Position/Title: Children’s and Behavioral Health Manager Name: Sarah Fisher Position/Title: CHIP Outreach Coordinator

Disclosure Statement This information is being collected to pursuant to 42 U.S.C. 1397aa, which requires states to submit a State Child Health Plan in order to receive federal funding. This mandatory information collection will be used to demonstrate compliance with all requirements of title XXI of the Act and implementing regulations at 42 CFR part 457. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). Public burden for all of the collection of information requirements under this control number is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26- 05, Baltimore, Maryland 21244-1850.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010, further modified the program. The HEALTHY KIDS Act and The Bipartisan Budget Act of 2018 together resulted in an extension of funding for CHIP through federal fiscal year 2027.

This template outlines the information that must be included in the state plans and the State plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. • Added new provisions related to delivery methods, including managed care, to section 3 (81 FR 27498, issued May 6, 2016) States are not required to resubmit existing State plans using this current updated template. However, States must use this updated template when submitting a new State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires the State to specify its proposed method of delivery. If the State proposes to use managed care, the State must describe and attest to certain requirements of a managed care delivery system, including contracting standards; enrollee enrollment processes; enrollee notification and grievance processes; and plans for enrolling providers, among others. (Section 2103); (42 CFR Part 457. Subpart L) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary-approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre-existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections:

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State plan amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Where the state’s assurance is requested in this document for compliance with a particular requirement of 42 CFR 457 et seq., the state shall place a check mark to affirm that it will be in compliance no later than the applicable compliance date.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

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

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

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

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

1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

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

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

1.1-DS

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

1.2.

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

1.3.

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

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

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

Original Plan Effective Date: July 1, 1988 (Title XIX expansion)

Implementation Date: July 1, 1988

Date Plan Submitted:

May 19, 1998 Date Plan Approved:

August 7, 1998 Effective Date:

July 1, 1998 (Title XIX expansion)

August 1, 1998 (Title XXI)

Amendment #1: Cover birth-18 185%-200%; no AI/AN cost sharing Date Submitted:

January 5, 2000 Date Approved:

March 1, 2001 Date Effective:

October 1, 1999

Amendment #2:

Hospice Date Submitted:

April 5, 2001 Date Approved:

June 6, 2001 Date Effective:

March 30, 2001

Amendment #3:

Compliance Date Submitted:

June 28, 2002 Date Approved:

September 19, 2002

Amendment #4:

Public health initiatives Date Submitted:

January 9, 2003 Date Approved:

April 16, 2003 Date Effective:

July 1, 2002

Amendment #5: Increase premiums for separate child health program Date Submitted:

October 6, 2004 Date Approved:

January 5, 2005 Date Effective:

November 1, 2004

Amendment #6:

DirigoChoice Date Submitted:

June 29, 2005 Date Effective:

January 1, 2005

Amendment #7: Expand eligibility to lawfully residing immigrant children (notwithstanding the 5-year bar);

Personnel changes; Departmental name changes;

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

DirigoChoice has been eliminated as a viable delivery system;

Health services initiatives (HSI);

Income disregard (effective September 1 2009);

Coverage option for legal immigrant children;

Enhanced Match for translation services (effective September 1, 2010); Technical corrections and clarifications. Date Submitted:

June 29, 2010 Date Effective: July 1, 2009, September 1, 2009, September 1, 2010 Date Implemented: July 1, 2009, September 1, 2009, September 1, 2010 Date Approved:

July 2, 2012

Amendment #8 ME-15-0012 Update the Federal Poverty Level (FPL) for which MaineCare will provide Title XXI funding for eligible children and for CubCare to comply with the Affordable Care Act.

Clarify the eligibility standards for children with coverage under other health insurance plans to reflect that children must be uninsured to be eligible for Tittle XXI and Title XIX funded coverage.

Date Submitted:

June 29, 2015 Date Effective

July 1, 2014

Amendment #9 ME-15-0015 Removed named vendors from the body of the CHIP State Plan.

Date Submitted: September 4, 2015 Date Effective:

July 1, 2015

Transmittal Number SPA Group PDF # Description

ME-13-0021

Effective/Implementation Date: January 1, 2014

MAGI Eligibility & Methods CS15

CS7

MAGI-Based Income Methodologies

Eligibility – Targeted Low Income Children

ME-13-033

Effective/Implementation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program ME-13-0022 Establish CS14 Children Ineligible for

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Transmittal Number SPA Group PDF # Description

Effective/Implementation Date: January 1, 2014 2101(f) Group Medicaid as a Result of the Elimination of Income Disregards ME-13-0023

Effective/Implementation Date: October 1, 2013 Eligibility Processing CS24 Eligibility Process ME-13-0024

Effective/Implementation Date: January 1, 2014 Non- Financial Eligibility CS17

CS18

CS19

CS20

CS21

CS27 Non-Financial Eligibility – Residency

Non-Financial Eligibility – Citizenship

Non-Financial Eligibility – Social Security Number

Non-Financial Eligibility – Substitution of Coverage

Non-Financial Eligibility – Non-Payment of Premiums

General Eligibility – Continuous Eligibility

SPA # ME-18.0014-CHIP Purpose of SPA: MHPAEA Date submitted: 7/2/2018

Proposed effective date: 7/1/2018

Proposed implementation date: 10/2/2017

Amendment #10 ME-17-003 Date Submitted: 12/5/2017 Date Effective: 1/1/2017

SPA #: ME-20-0006-B Purpose of SPA: Disaster Relief - To implement provision for temporary adjustments to enrollment and redetermination policies and cost sharing requirements for children in families living and/or working in Governor or FEMA declared disaster areas. In the event of a disaster, the State will notify CMS that it intends to provide temporary adjustments to its enrollment and redetermination policies and cost sharing requirements, the effective and duration date of such adjustments, and the applicable Governor or FEMA declared disaster areas.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

SPA# ME-20-0006 Non-Financial Eligibility - Non-Payment of Premiums submitted through MMDL with this amendment, adds an exception to the lock-out period for individuals in disaster areas.

Proposed effective date: March 1, 2020 Maine is seeking to implement the plan outlined within Sections 4.3, 8.2, and 8.7 until the State or Federal emergency has been lifted, whichever is later. Proposed implementation date: March 1, 2020

SPA# ME-20-0027 Purpose of SPA: CHIP Health Services Initiatives (HSI) coverage. Maine is seeking coverage for two new Health Service Initiatives and refunding an existing initiative aimed at improving the health and wellness of low income youth by leveraging federal funding for current child health programs and to increase access to EPSDT required developmental screens.

Proposed effective date: October 1, 2020 Maine has updated the template in Sections 1.4, 1.4-TC, Section 2.2, and Section 9.10. Proposed implementation date: October 1, 2020

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

A tribal consultation call between state officials and tribal leaders was held August 6, 2020. Following the call, letters to the tribal leaders further describing the changes were mailed August 26, 2020. A tribal consultation call between state officials and tribal leaders was held August 6, 2020. Following the call, letters to the tribal leaders further describing the changes were mailed August 26, 2020.

TN No: Approval Date Effective Date

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

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

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description. • Population • Number of uninsured

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 • Race demographics • Age Demographics • Info per region/Geographic information

2.1. Describe the extent to which, and manner in which, children in the State (including targeted low-income children and other groups of children specified) identified , by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102(a)(1)); (42 CFR 457.80(a))

Currently, no public-private partnerships exist in Maine.

According to the Kaiser Family Foundation’s statehealthfacts.org, Health Insurance coverage of Children 0-18 (2008-2009) in Maine: • 52% of children have employer sponsored health coverage • 4% of children have individually purchased health coverage • 37% of children have Medicaid coverage (CHIP is included) • 5% of children are uninsured.

Maine’s rate of uninsured children 0-18 is 7% for children under 200% of Federal Poverty Level.

Maine is not as racially and ethnically diverse as most other states as 95% of the population is identified as white. The poverty rate by race/ethnicity is 14% for individuals identified as white and 34% for individuals identified as “other.”

The poverty rate by Metropolitan status is 13% for those living in metropolitan areas and 17% for those living in non-metropolitan areas. The majority of Maine is considered to be rural by the federal government.

The information above is taken from Current Population Survey data (2008- 2009) statistics are all from www.statehealthfacts.org.

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

Lead Abatement:

The Department plans to use HSI funds to expand the reach of lead abatement activities in Maine, to improve the well-being of families with children, and to

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 maintain access to affordable housing that is lead safe. State law (P.L. 2018, Ch. 460) requires that the Department inspect every housing unit in a multi-unit dwelling building when a lead poisoned child is found in any individual unit. If lead hazards are identified, they must be abated using State licensed abatement contractors who permanently remove lead hazards using methods established by state and federal regulations. This HSI would expand Maine’s current state-funded lead abatement efforts established by law in 2018 (Public Law 2018 Chapter 460). This abatement program is administered by Maine Housing and provides grants for up to 90% of the cost to abate lead paint hazards in residential housing units or housing projects. State law restricts this grant program to households with incomes up to 100% of the area median income and requires that grant funding prioritize abatement projects for housing in which a child has been determined to be lead poisoned. Information on Area Median Income calculations is located at https://www.mainehousing.org/docs/default-source/homeimprovement/2020-100- median-income-limits.pdf?sfvrsn=37e38d15.

It is well established that there is no safe level of lead in children’s blood. Maine has been proactive in addressing childhood lead poisoning by being one of the first states to require full environmental inspections (presence of lead paint in poor condition, dust lead hazards, soil lead hazards, water lead hazards) whenever a child is identified with a blood lead level that is at or above the revised CDC blood lead reference level of 5 ug/dL. In 2018, an estimated 350 children under 6 years of age were identified as having a blood lead level of 5 ug/dL or above. Nearly 75% of Maine children identified as having an elevated blood lead level are enrolled in Maine’s Medicaid program, and about 70% of children with high blood lead levels live in rental housing, with the rest in single-family owner-occupied housing.

State law requires the issuance of orders to abate identified lead hazards in rental properties and provides discretionary authority with respect to single-family owner- occupied homes. With increased inspection activity has come an increase in lead abatement orders, resulting in an increased need for funds to abate identified lead hazards so that housing can be made lead-safe and remain affordable. This program will improve the health and well-being of children by increasing the availability of housing that has been made lead safe, resulting in fewer children needing specific services, including special education services, as a result of lead poisoning. It will also improve the well-being of families with children by maintaining access to affordable housing, as the grant program requires a four-year commitment by the owner to lease units to households at or below 100% of the area median income and that rent not exceed 30% of the area median income. Lead abatement activities will be supported state-wide. This said, particular attention will be paid to the Lewiston/Auburn area, which has the highest rates of lead poisoning which is impacting a racially and ethnically diverse population. The state has received a HUD Choice Award with a goal of supporting the Lewiston/Auburn area being lead free by 2043. This HSI would support achieving the state’s goal.

To be eligible for this HSI, Maine Housing Authority works with the client requesting lead abatement funds to determine which lead program (federal or state) works best for the client project. Households with income above 80% AMI and not

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 above 100% AMI are enrolled in the State Lead Program. Maine CDC and Maine Housing Authority will establish an MOU to specifically govern eligibility to target MaineCare (including State Medicaid and CHIP) eligible children. Priority will be given to dwellings associated with referrals from Maine CDC based on the identification of children with elevated blood lead levels (.5ug/dL). Eligibility will be determined in the same manner as currently conducted under U.S. HUD Lead Hazard Control Grant funds.

Funding for this HSI will be $954,000 total state and federal funds annually. The HSI funds would provide financing for approximately fifty additional houses to be lead abated, which includes a six percent admin cost necessary for lead abatement. State match will be provided through dedicated funds for lead abatement through the Fund for Healthy Maine.

The state will track and report key metrics related to the lead abatement program to CMS quarterly or at another approved interval.

Lead Testing:

In June of 2019, Maine law required universal lead testing of children at one and two years of age. For children enrolled in MaineCare, these testing rates have been low: 52-55% of children at age one and 35-36% of children at age two. The lead program has noticed a decrease in testing during the COVID-19 pandemic due to operational challenges, reduced well visits, and inability to do point of care testing in office due to a lack of appropriate testing equipment on site.

The HSI will focus on increasing lead testing rates by conducting a quality improvement project between MaineCare and the Maine CDC’s Childhood Lead Poisoning Prevention Unit. MaineCare and the Maine CDC will identify primary care practices with both low testing rates and large numbers of children enrolled in MaineCare. HSI funds will allow for the purchase of ten point-of-care lead level testing machines to distribute to these high priority practices. The Childhood Lead Poisoning Prevention Unit will provide quality improvement (QI) support to the practices, including QI education, review of practice data, and assistance with workflow.

Funding for this HSI will be $30,000 total state and federal funds annually. State match will be provided by private philanthropy supporting state child health initiatives. HSI funds will be used to finance ten point of care LeadCareII lead level testing machines valued at $3,000 each. Eligible health practices for the point of care lead testing machine will be those practices that serve a high percentage of MaineCare and CHIP eligible children in their communities, a volume of between 200 and 400 children ages one to two years of age, and for which the purchasing of a LeadCareII machine is a barrier (i.e., greater than a two-year payback period).

Communication and Media to Promote Tobacco Prevention – This HSI provides grants to a contractor to develop a statewide marketing campaign for the Partnership for a Tobacco-Free Maine to promote tobacco prevention among children and youth.

Funding for this HSI will be $200,000 total state and federal funds annually. The HSI funding will support financing prevention materials and quitting materials, and

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 will allow for a broader implementation of the campaign to reach more low income youth. State match will be provided through general fund dollars.

School Based Health Centers – This HSI provides grants to schools and/or medical providers to build or expand capacity at school based health centers where the school based health centers provide support for public health functions: educating future adult health care consumers on healthy behaviors and on the use of health care; providing diagnosis and treatment of acute illness and management of chronic conditions; and education, assessment, counseling, and referrals to community-based providers. Mental health, reproductive health and oral health services may also be provided in a school-based health center.

Family Planning, Adolescent Pregnancy Prevention Services - This HSI provides grants to providers to conduct outreach campaigns to promote family planning among adolescents where the providers support family life education consultation programs for schools and communities as well as community based adolescent pregnancy prevention projects. Outreach educators provide comprehensive family life education that includes information about abstinence and information on preventing sexually transmitted diseases and birth control. Examples of activities include: interactive workshops for youth, educational displays at health fairs for teens, and office hours at teen centers.

This HSI can also include a grant to a provider who, along with delegate agencies across the state, provides clinical reproductive health services to adolescents and low income women. Services include: contraceptives, screening, diagnosis and treatment of sexually transmitted infections, and breast and cervical cancer screening. This grantee also provides funds, training/technical assistance and resources to communities with high teen pregnancy rates to help them select and implement evidence-based teen pregnancy prevention programs. In addition, they provide professional development opportunities, technical assistance and support to community and school health educators on topics such as puberty, healthy relationships, contraception, sexually transmitted infections and parent involvement.

Maine Families Home Visiting Program – This HSI provides funding to community agencies for the provision of home visiting services for first time families and pregnant and parenting adolescents. This Home Visiting Service (The Maine Families Program) is housed and run by the Office of Child and Family Services (OCFS). The statewide network of these programs is called Maine Families (Home Visiting) and funded entirely by the Fund for Healthy Maine special revenue.

2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)); (ARRA #2, CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice.

Plan amendments, waiver requests, and proposals for demonstration projects will be identified as having a direct effect on Indians, Indian health programs, or urban Indian organizations as part of a two tier consultation.

The first tier involves written notices of any changes, sent electronically and via email to tribal representatives.

The second tier involves direct consultation (phone conversations, face-to-face meetings, direct email communications) with Tribes when there is any change or update in policy that effect any services that Tribes are reimbursed for through MaineCare. Issues identified as having a direct effect on the Tribes will be raised in monthly meetings or via listserv at least 30 days in advance of submission to CMS.

Tribal representatives are also invited as a MaineCare Advisory Committee (MAC) member, to be part of all policy development and to provide feedback to the Department in an advisory capacity.

Tribal representatives are also assigned a dedicated provider relations specialist to provide technical assistance in claims adjudication.

Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4. Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed health care plans (including fully and partially capitated plans); contracts with indemnity health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems.

Should the State choose to cover unborn children under the Title XXI State plan, the State must describe how services are paid. For example, some states make a global payment for all unborn children while other states pay for services on fee-for- services basis. The State’s payment mechanism and delivery mechanism should be briefly described here.

Section 2103(f)(3) of the Act, as amended by section 403 of CHIPRA, requires separate or combination CHIP programs that operate a managed care delivery system to apply several provisions of section 1932 of the Act in the same manner as these provisions apply under title XIX of the Act. Specific provisions include:

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. If the State CHIP program operates a managed care delivery system, provide an assurance that the State CHIP managed care contract(s) complies with the relevant sections of section 1932 of the Act. States must submit the managed care contract(s) to the CMS Regional Office servicing them for review and approval.

In addition, states may use up to 10 percent of actual or estimated Federal expenditures for targeted low-income children to fund other forms of child health assistance, including contracts with providers for a limited range of direct services; other health services initiatives to improve children’s health; outreach expenditures; and administrative costs (See 2105(c)(2)(A)). Describe which, if any, of these methods will be used.

Examples of the above may include, but are not limited to: direct contracting with school-based health services; direct contracting to provide enabling services; contracts with health centers receiving funds under section 330 of the Public Health Service Act; contracts with hospitals such as those that receive disproportionate share payment adjustments under section 1886(d)(5)(F) or 1923 of the Act; contracts with other hospitals; and contracts with public health clinics receiving Title V funding. If applicable, address how the new arrangements under Title XXI will work with existing service delivery methods, such as regional networks for chronic illness and disability; neonatal care units, or early-intervention programs for at-risk infants, in the delivery and utilization of services. (42 CFR 457.490(a))

3.1. Delivery Standards Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42 CFR 457.490(a))

MaineCare, both Title XIX and Title XXI funded coverage, is administered by the Maine Department of Health and Human Services. Within the Department, MaineCare Services is responsible for establishing policy regarding benefits, quality assurance, and claims payment. The Office for Family Independence is responsible for determining eligibility. MaineCare does not provide any medical services through a managed care entity.

Children covered under MaineCare with Title XXI funding are provided with the same rights and benefits available to children enrolled with Title XIX funding. All administrative processes are designed by the Department of Health and Human Services to be seamless. As such, all enrollment and eligibility processes, benefit package/benefit delivery policies, and outreach activities are the same for Title XIX and Title XXI, with the only discernable difference being premium billing for those Title XXI children at 151% through 200% FPL.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

There are 2 delivery systems. (1) The MaineCare Primary Care Case Management (PCCM) program is operational in all 16 counties. PCCM assigns each child to a physician or nurse practitioner to coordinate all health care services. The majority of MaineCare children covered under Title XXI and Title XIX access services through PCCM. Providers participating in the PCCM program receive a per member, per month fee for each child assigned to their practice. In addition, providers who meet quality targets (and are not affiliated with hospitals) receive an incentive payment based on their performance and number of members served.

(2) MaineCare members not participating in primary care case management can access services through the fee for service system, meaning that they can choose any provider who is enrolled with MaineCare and are not required to have their health care coordinated by their primary care physician. Since the member is not assigned to a physician practice for coordination of care, no per member, per month fee is paid to the practice for the coordination of care.

Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act, including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS Regional Office for review and approval. (Section 2103(f)(3))

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after- hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b))

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102)(a)(4) (42 CFR 457.490(b))

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

1. Primary Care Providers – Under the primary care case management initiative, each MaineCare member has a Primary Care Provider who is responsible for managing (treating or referring out for treatment) the member’s health care. MaineCare members must receive authorization from their Primary Care Provider for those covered MaineCare services designated as ‘managed services’. For those MaineCare covered services that do not require PCP authorization members may self-refer or seek prior authorization, as is noted below.

2. Prior Authorization – Prior authorization is required for certain MaineCare covered services obtained in-state and all MaineCare covered services provided out-of-state (with the exception of emergency services and services furnished by providers located within 15 miles of the New Hampshire border and 5 miles of Canadian border who are treated as in-state providers). All services requiring prior authorization are reviewed for medical necessity. Prior authorization for services rendered out-of-state is provided only when a member’s continuity of care must be preserved for medical reasons and only after it is determined that the needs of the member cannot be met in the State of Maine.

3. Utilization Review – Ongoing monitoring of health care received by MaineCare members is provided by staff of the Program Integrity Unit within the Division of Audit. Ongoing sampling is conducted to review the utilization of care and services received by MaineCare members and also to evaluate necessity, quality, quantity and timeliness of services provided to MaineCare members.

4. Member Restriction – Member restriction is an administrative procedure established for MaineCare members with a history of over utilization of benefits. Participants must receive their primary medical care from one (or multiple specified providers). Primary purposes for restricting members to specified provider(s) are: 1) to decrease and control over utilization and/or abuse of covered health care services/benefits and to minimize medically unnecessary and addictive drug usage; 2) to establish a method of monitoring non-emergency health care services for members who have utilized health care services or benefits at a frequency or amount that is not medically necessary; and 3) to assist members through education and referral towards appropriate health care service and benefit use.

5. Utilization Report/Primary Care Physician Incentive Payment Report – Member utilization is also measured through preventive/quality indicators presented to MaineCare primary care providers in the Utilization Report on a quarterly basis, and on a bi-annual basis in the Primary Care Physician Incentive Payment Report. The Utilization Report contains 25 performance measures centered on well-child care, utilization of emergency services, potentially avoidable hospitalizations for chronic/serious medical conditions, and other disease prevention measures. The Primary Care Physician Incentive Payment Report contains additional performance measures focused on preventive indicators. (These reports are described in more detail in Section 7.)

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Section 4. Eligibility Standards and Methodology

Guidance: States electing to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan or combination plan should check the appropriate box and provide the ages and income level for each eligibility group. If the State is electing to take up the option to expand Medicaid eligibility as allowed under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as well as update the budget to reflect the additional costs if the state will claim title XXI match for these children until and if the time comes that the children are eligible for Medicaid.

4.0.

Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group:

4.1.

Separate Program Check all standards that will apply to the State plan. (42CFR 457.305(a) and 457.320(a))

4.1.0 Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option.

The State has opted to use the SSA verification option. In the case of non-citizens, the State uses SAVE verification through DHS

4.1.1 Geographic area served by the Plan if less than Statewide:

Statewide

4.1.2 Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group:

Individuals must be under 19 years of age

4.1.2.1-PC Age: through birth (SHO #02-004, issued November 12, 2002)

4.1.3 Income of each separate eligibility group (if applicable):

The upper income limit for Title XXX is 200% FPL

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through 208% of the FPL (SHO #02-004, issued November 12, 2002)

4.1.4 Resources of each separate eligibility group (including any standards relating to spend downs and disposition of resources):

4.1.5 Residency (so long as residency requirement is not based on length of time in state): To be eligible for MaineCare, a child must be a resident of the State of Maine

4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility):

4.1.7 Access to or coverage under other health coverage:

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Children must be uninsured to be eligible for Title XXI funded coverage. Children who are eligible for Medicaid expansion coverage funded by Title XXI may not have other health coverage; children with other coverage eligible for Medicaid will be funded by Title XIX.

4.1.8 Duration of eligibility, not to exceed 12 months: In general, a child who has been determined eligible for MaineCare shall remain eligible for 12 months unless the child attains the age of 19 or is no longer a resident of the State. Eligibility is redetermined prior to the end of each twelve-month period. A child may be ineligible for a subsequent 12-month period of eligibility for a specified length of time) as described in section 8.7) for nonpayment of premiums.

4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 457.310 and 457.320 that are not addressed above. For instance: The Office for Family Independence MaineCare Eligibility Manual sets for the eligibility policies for Titles XIX and XXI.

Guidance: States may only require the SSN of the child who is applying for coverage. If SSNs are required and the State covers unborn children, indicate that the unborn children are exempt from providing a SSN. Other standards include but are not limited to presumptive eligibility and deemed newborns.

4.1.9.1

States should specify whether Social Security Numbers (SSN) are required. All applicants are asked for their SSN. It is required except for undocumented non-citizens or a child born to a mother on Medicaid at time of birth. For these “golden babies,” applications for SSN or SSN must be provided by the child’s first birthday. A child born to a mother not receiving Medicaid at time of birth must have SSN requirements met by first day of the second month following month in which the mother is discharged from the hospital. Cub Care applicants who receive either SS or SSDI, or Medicare, do not need to provide their SSN.

Guidance: States should describe their continuous eligibility process and populations that can be continuously eligible.

4.1.9.2 Continuous eligibility

We provide continuous eligibility for CHIP. A child who has been determined eligible shall remain eligible for 12 months unless the child attains the age of 19 or is no longer a resident of the State.

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

Maine does not elect the pregnant woman option for CHIP.

Guidance: States have the option to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1) “lawfully residing” children described at section 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

4.1- LR

Lawfully Residing Option (Sections 2107(e)(1)(J) and 1903(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status 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) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following 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. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24);

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 (iv) Family Unity beneficiaries pursuant to section 301 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 who 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 INA (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 least180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. §1101(a)(27)(J)); (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.

Elected for pregnant women. Elected for children under age 19

4.1.1-LR The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, 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 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.

4.1-DS

Supplemental Dental (Section 2103(c)(5) - A child who is eligible to enroll in dental-only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

4.2. Assurances The State assures by checking the box below that it has made the

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 following findings with respect to the eligibility standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

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

4.2.2. Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. This applies to pregnant women included in the State plan as well as targeted low-income children.

4.2.3. These standards do not deny eligibility based on a child having a pre- existing medical condition. This applies to pregnant women as well as targeted low- income children.

4.2-DS Supplemental Dental - Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1-DS These standards do not discriminate on the basis of diagnosis.

4.2.2-DS Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income.

4.2.3-DS These standards do not deny eligibility based on a child having a pre-

existing medical condition.

4.3. Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section 2102)(b)(2)) (42CFR, 457.350) All administrative processes are designed by the Department of Health and Human Services to be seamless for children applying for MaineCare. As such, all enrollment and eligibility processes are the same for Title XIX and Title XXI, with the only discernable difference being premium billing for those Title XXI children at 158% through 208% FPL.

There is one application and renewal form for families and children who want to apply for MaineCare coverage. The Department of Health and Human Services, Office for Family Independence eligibility specialists determine if applicants are eligible for Title XIX or XXI coverage depending on family income.

Eligibility applications may be completed at any of the Department’s regional offices, online, or at home and returned by mail/fax. No interview is necessary.

The Office for Family Independence notifies families of their eligibility by mail. Those eligible Title XXI children at 158% through 208% FPL are, in addition to their enrollment cards, mailed monthly premium bills (please see Section 8.2).

A child who has been determined eligible for MaineCare remains eligible for a 12

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 month enrollment period unless the child attains the age of 19 or is no longer a resident of the State. Eligibility is redetermined prior to the end of each 12 month period. Written notification is sent to each family by the Office for Family Independence containing the end date of the child’s 12-month enrollment period and a renewal form to be completed online or returned by mail upon completion.

In summary, MaineCare policy requires eligibility specialists to review all applications, denials, closings, changes in MaineCare Title XIX funded coverage for Title XXI funded coverage and vice versa.

Families are allowed to purchase coverage for a child whose family income at the end of the 12-month enrollment period exceeds 208% of FPL. The purchase of coverage is available for 18 months. The child’s family is responsible for paying the full cost of the coverage, which covers the benefit cost plus an administrative cost not to exceed the maximum allowable under COBRA.

CHIP Disaster Relief: At State discretion, the following may be temporarily waived for CHIP applicants and beneficiaries who reside and/or work in a State or Federally declared disaster area: • requirements related to timely processing of applications; • requirements related to timely processing of renewals and/or deadlines for families to respond to renewal requests; and • eligibility verification requirements at application and renewal – the State may allow self-attestation to complete the eligibility determination

Guidance: The box below should be checked as related to children and pregnant women. Please note: A State providing dental-only supplemental coverage may not have a waiting list or limit eligibility in any way.

4.3.1. Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(2)) (42CFR, 457.305(b))

In order to provide health coverage to as many children as possible within the fiscal constraints of the program budget (as defined in the Balanced Budget Act of 1997), the maximum eligibility level is subject to adjustment by the Commissioner of the Department dependent on the fiscal status of the program. If program expenditures are anticipated to exceed the program budget, the Commissioner shall reduce the maximum eligibility level to the extent necessary to bring the program expenditures within the program budget. If expenditures are expected to fall below the program budget, the Commissioner shall increase the maximum eligibility level to the extent necessary to provide coverage to as many children as possible within the fiscal constraints of the program budget.

Children of higher income may not be covered unless children of lower income are also covered. If the Commissioner has reduced the maximum eligibility level, children of higher income may be disqualified at the end of the twelve month enrollment period, but not during the twelve-month period.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Check here if this section does not apply to your State.

Guidance: Note that for purposes of presumptive eligibility, States do not need to verify the citizenship status of the child. States electing this option should indicate so in the State plan. (42 CFR 457.355)

4.3.2. Check if the State elects to provide presumptive eligibility for children that meets the requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR 457.355)

Guidance: Describe how the State intends to implement the Express Lane option. Include information on the identified Express Lane agency or agencies, and whether the State will be using the Express Lane eligibility option for the initial eligibility determinations, redeterminations, or both.

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

4.3.3.1-EL Also indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

4.3.3.2-EL List the public agencies approved by the State as Express Lane agencies.

4.3.3.3-EL List the components/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option.

4.3.3.3-EL List the component/components of CHIP eligibility that are determined under the Express Lane.

4.3.3.4-EL Describe the option used to satisfy the screen and enrollment requirements before a child may be enrolled under title XXI.

Guidance: States should describe the process they use to screen and enroll children required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe the screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by an Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated. Describe whether the State is temporarily enrolling children in CHIP, based on the income finding from an Express Lane agency, pending the completion of the screen and enroll process.

In this section, states should describe their eligibility screening process in a way that addresses the five assurances specified below. The State should consider including important definitions, the relationship with affected Federal, State and local agencies, and other applicable criteria that will describe the State’s ability to make assurances. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)), (42 CFR 457.310(b)(2), 42CFR 457.350(a)(1) and 457.80(c)(3))

4.4. Eligibility screening and coordination with other health coverage programs States must describe how they will assure that:

4.4.1. only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance (including access to a State health benefits plan) are furnished child health assistance under the plan. (Sections 2102(b)(3)(A), 2110(b)(2)(B)) (42 CFR 457.310(b), 42 CFR 457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women.

The State of Maine Does not cover pregnant women through CHIP.

As noted in Section 4.3, the same application and enrollment process is used by all families applying for coverage under MaineCare. A child applying for coverage under MaineCare is first screened by the Office for Family Independence eligibility specialists for eligibility under Title XIX. Those children deemed ineligible under Title XIX are then screened for eligibility under Title XXI.

Applicants are asked to provide insurance information a part of the application process. Specific questions on the application ask about children in the household who: (1) currently have insurance; (2) have lost health insurance in the last 3 months; and (3) could be added to the State employee health insurance plan. Depending on the answer to these questions, the Office for Family Independence specialists will determine if an applicant is eligible for Title XXI funded coverage. Children made eligible under Title XIX may have other health insurance coverage.

The same process is followed for subsequent eligibility determinations.

4.4.2. children found through the screening process to be potentially eligible for medical assistance under the State Medicaid plan are enrolled for assistance under such plan; (Section 2102(b)(3)(B)) (42CFR, 457.350(a)(2))

Please see 4.4.1 above

4.4.3. children found through the screening process to be ineligible for Medicaid are enrolled in CHIP; (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

Please see 4.4.1 above

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

4.4.4. the insurance provided under the State child health plan does not substitute for coverage under group health plans. (Section 2102(b)(3)(C)) (42CFR, 457.805)

4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premium assistance program, describe: 1) the minimum period without coverage under a group health plan. This should include any allowable exceptions to the waiting period; 2) the expected minimum level of contribution employers will make; and 3) how cost- effectiveness is determined. (42CFR 457.810(a)-(c)) Coverage is provided to children in families at or below 208% FPL. Applicants are asked to provide insurance information as part of the application process. Specific questions on the application ask about children in the household who: (1) currently have insurance; and (2) have lost health insurance in the last 3 months;. There is a 3 month waiting period for children who drop employer based coverage- with the exception of state employees who were provided a one year waiver of this requirement, beginning at the date of SPA approval for allowing state employees to enroll.

The child may enroll without having to wait 3 months if:  The employer plan does not pay at least 50% of the cost of the child’s coverage;  The cost of covering the whole family under the employer’s plan is more than 10% of the family income;  The Department determines that good cause exists for dropping the employer based coverage.

In addition, eligibility records are matched against third party liability records to cross check to see if the third party liability records indicate that other insurance is available. A list of members whose eligibility is determined through Title XXI identified as having insurance is sent to the Office for Family Independence eligibility specialists to review

4.4.5. Child health assistance is provided to targeted low-income children in the State who are American Indian and Alaska Native. (Section 2102(b)(3)(D)) (42 CFR 457.125(a)) Any eligible child who is American Indian or Alaskan Native is enrolled in MaineCare under Title XIX or Title XXI and treated as any other eligible child, with the exception that the child is not required to pay a premium or other cost sharing.

Under the provisions enacted in CHIPRA for Title XIX or Title XXI, MaineCare accepts tribal enrollment documents issued by a Federally-recognized Indian tribe evidencing membership or affiliation with such tribe, as proof of U.S. citizenship; and encourages outreach and enrollment of Indians. The Office for Family

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Independence makes efforts to routinely meet with tribal organizations to help streamline access to eligibility, and provide translation services, and education regarding Medicaid and CHIP. In addition, the MaineCare Services will consult with tribal organizations on continued development and implementation of the CHIP State Plan through ongoing scheduled meetings.

Guidance: When the State is using an income finding from an Express Lane agency, the State must still comply with screen and enroll requirements before enrolling children in CHIP. The State may either continue its current screen and enroll process, or elect one of two new options to fulfill these requirements.

4.4-EL The State should designate the option it will be using to carry out screen and enroll

requirements:

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 42 CFR 457.80(c). Describe this process.

The State is establishing a screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by the Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process.

Section 5. Outreach and Coordination

5.1. (formerly 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2. (Section 2102)(a)(2) (42 CFR 457.80(b))

Guidance: The information below may include whether the state elects express lane eligibility a description of the State’s outreach efforts through Medicaid and state-only programs.

5.1.1. (formerly 2.2.1.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 The agency will provide outreach, education and toll-free helpline response assistance on MaineCare and other public and private coverage programs on a statewide basis. The functions include worksite and community-based trainings; provide requested information and referral if appropriate, screen for eligibility for various coverage programs, send packets of information including applications where appropriate, assist with completing applications where appropriate; and design and produce mailings with information about changes in benefits or coverage, open enrollment periods, or other important updates.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

State staff from the MaineCare Services, the Maine Center for Disease Control and Prevention, and Children’s Behavioral Health Services will be reimbursed at the higher CHIP administrative match for program planning, data analysis, oversight of quality and outreach to providers on behalf of children.

MaineCare has an arrangement with the Maine Department of Education to send an informational flyer home with children at the beginning of the school year informing parents about the availability of CHIP coverage and providing information about how to apply.

On an ongoing basis, the Department’s outreach efforts and goals include:

• Technical training with staff of community based agencies and health care providers on benefits, eligibility criteria, the application process and program changes to ensure information is disseminated and individuals are enrolled. Each participant is provided with a guide containing the training information. Participants are asked to make a commitment to provide long-term outreach and application assistance to the clients they serve. This model, of reaching potentially eligible individuals through trained personnel with whom they have established relationships, has proven an effective outreach method.

• Mass media interventions through annual statewide/local media events. Three events are held each year to highlight availability of health care coverage. Events often coincide with national campaigns, such as Cover the Uninsured Week.

• Targeted outreach to specific constituencies including: Education; Businesses and unions; Social service agencies and municipalities; Faith- based and service organizations; Health care providers and insurers.

• Distribution of electronic newsletter to interested parties. The newsletter contains information on MaineCare and other health care coverage programs (e.g. Dirigo) as well as the overall efforts of the campaign.

• General training for community organizations such as the Kiwanis, Elks, Lions Clubs, etc. General trainings also provided to statewide organizations such as the Association of Health Care Administrators – Maine, General Assistance Administrators, WIC Directors.

• Information booths at health fairs, professional conferences, e.g., Maine Pediatric Association meetings.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 • Grass roots outreach by local coalitions such as attendance at local kindergarten registration events; local promotional events (e.g., providing application assistance booth during school carnival).

The Department’s efforts to assist individuals in enrolling include:

1. HelpLine—Maintenance of a statewide toll free HelpLine where trained workers: a.) inform callers of coverage options and assist with application or reenrollment process; b.) provide information about application assistance sites or other appropriate services/programs in the geographical area; c.) serve as resource to hundreds of sites trained to provide application assistance.

2. Expanded Application Capacity—Maintenance and expansion of statewide sites available to provide applications and application assistance (including reenrollment).

The Department also gathers information from constituencies, local coalitions, technical trainings, and HelpLine calls to identify problems or barriers families are encountering in accessing or continuing coverage for their children

Guidance: The State may address the coordination between the public-private outreach and the public health programs that is occurring statewide. This section will provide a historic record of the steps the State is taking to identify and enroll all uninsured children from the time the State’s plan was initially approved. States do not have to rewrite his section but may instead update this section as appropriate.

5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in health insurance programs that involve a public-private partnership:

No public-private partnerships currently exist in Maine.

Guidance: The State should describe below how it’s Title XXI program will closely coordinate the enrollment with Medicaid because under Title XXI, children identified as Medicaid- eligible are required to be enrolled in Medicaid. Specific information related to Medicaid screen and enroll procedures is requested in Section 4.4. (42 CFR 457.80(c))

5.2. (formerly 2.3) Describe how CHIP coordinates with other public and private health insurance programs, other sources of health benefits coverage for children, other relevant child health programs, (such as title V), that provide health care services for low-income children to increase the number of children with creditable health coverage. (Section 2102(a)(3), 2102(b)(3)(E) and 2102(c)(2)) (42 CFR 457.80(c)). This item requires a brief overview of how Title XXI efforts – particularly new enrollment outreach efforts – will be coordinated with and improve upon existing State efforts.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 There are no public programs in the state, except MaineCare, that provide health care coverage for low-income children. Because the enrollment application for CHIP is integrated with the enrollment application for Medicaid, determination of eligibility is automatically and seamlessly integrated between the two programs.

The Title V program provides very limited care coordination to children with Special Health Care needs who are not eligible for public coverage for children who are generally uninsured or underinsured.

5.2-EL The State should include a description of its election of the Express Lane eligibility option to provide a simplified eligibility determination process and expedited enrollment of eligible children into Medicaid or CHIP.

Guidance: Outreach strategies may include, but are not limited to, community outreach workers, outstationed eligibility workers, translation and transportation services, assistance with enrollment forms, case management and other targeting activities to inform families of low-income children of the availability of the health insurance program under the plan or other private or public health coverage.

The description should include information on how the State will inform the target of the availability of the programs, including American Indians and Alaska Natives, and assist them in enrolling in the appropriate program.

5.3. Strategies Describe the procedures used by the State to accomplish outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program. (Section 2102(c)(1)) (42 CFR 457.90)

The agency will provide outreach, education and toll-free helpline response assistance on MaineCare and other public and private coverage programs on a statewide basis. The functions include worksite and community-based trainings; provide requested information and referral if appropriate, screen for eligibility for various coverage programs, send packets of information including applications where appropriate, assist with completing applications where appropriate; and design and produce mailings with information about changes in benefits or coverage, open enrollment periods, or other important updates.

State staff from the MaineCare Services, the Maine Center for Disease Control and Prevention, and Children’s Behavioral Health Services will be reimbursed at the higher CHIP administrative match for program planning, data analysis, oversight of quality and outreach to providers on behalf of children.

MaineCare has an arrangement with the Maine Department of Education to send an informational flyer home with children at the beginning of the school year informing parents about the availability of CHIP coverage and providing information about how to apply.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

On an ongoing basis, the Department’s outreach efforts and goals include:

• Technical training with staff of community based agencies and health care providers on benefits, eligibility criteria, the application process and program changes to ensure information is disseminated and individuals are enrolled. Each participant is provided with a guide containing the training information. Participants are asked to make a commitment to provide long-term outreach and application assistance to the clients they serve. This model, of reaching potentially eligible individuals through trained personnel with whom they have established relationships, has proven an effective outreach method.

• Mass media interventions through annual statewide/local media events. Three events are held each year to highlight availability of health care coverage. Events often coincide with national campaigns, such as Cover the Uninsured Week.

• Targeted outreach to specific constituencies including: Education; Businesses and unions; Social service agencies and municipalities; Faith- based and service organizations; Health care providers and insurers.

• Distribution of electronic newsletter to interested parties. The newsletter contains information on MaineCare and other health care coverage programs (e.g. Dirigo) as well as the overall efforts of the campaign.

• General training for community organizations such as the Kiwanis, Elks, Lions Clubs, etc. General trainings also provided to statewide organizations such as the Association of Health Care Administrators – Maine, General Assistance Administrators, WIC Directors.

• Information booths at health fairs, professional conferences, e.g., Maine Pediatric Association meetings.

• Grass roots outreach by local coalitions such as attendance at local kindergarten registration events; local promotional events (e.g., providing application assistance booth during school carnival).

The Department’s efforts to assist individuals in enrolling include:

1. HelpLine—Maintenance of a statewide toll free HelpLine where trained workers: a.) inform callers of coverage options and assist with application or reenrollment process; b.) provide information about application assistance sites or other appropriate services/programs in the geographical area; c.) serve as resource to hundreds of sites trained to provide application assistance.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

2. Expanded Application Capacity—Maintenance and expansion of statewide sites available to provide applications and application assistance (including reenrollment).

The Department also gathers information from constituencies, local coalitions, technical trainings, and HelpLine calls to identify problems or barriers families are encountering in accessing or continuing coverage for their children

Section 6. Coverage Requirements for Children’s Health Insurance

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

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

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

6.1.1.

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

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

6.1.1.1.

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

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

6.1.1.2.

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

Guidance: Check box below if the benchmark benefit package to be offered by the State is offered by a health maintenance organization (as defined in Section 2791(b)(3) of the Public Health Services Act) and has the largest

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 insured commercial, non-Medicaid enrollment of covered lives of such coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42 CFR 457.420(c)))

6.1.1.3.

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

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

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

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan,

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431.

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

6.1.3.

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

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

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) Guidance: Section 1905(r) of the Act defines EPSDT to require coverage of (1) any medically necessary screening, and diagnostic services, including vision, hearing, and dental screening and diagnostic services, consistent with a periodicity schedule based on current and reasonable medical practice standards or the health needs of an individual child to determine if a suspected condition or illness exists; and (2) all services listed in section 1905(a) of the Act that are necessary to correct or ameliorate any defects and mental and physical illnesses or conditions discovered by the screening services, whether or not those services are covered under the

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Medicaid state plan. Section 1902(a)(43) of the Act requires that the State (1) provide and arrange for all necessary services, including supportive services, such as transportation, needed to receive medical care included within the scope of the EPSDT benefit and (2) inform eligible beneficiaries about the services available under the EPSDT benefit.

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

6.1.4.1.

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

6.1.4.2.

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

6.1.4.3.

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

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

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage.

6.1.4.5.

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

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

6.1.4.6.

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Guidance: Check below if the State elects to provide a source of coverage that is not described above. Describe the coverage that will be offered, including any benefit limitations or exclusions.

6.1.4.7.

Other. (Describe)

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

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

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

6.2.1.

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

6.2.2.

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

6.2.3.

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

6.2.4.

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

6.2.5.

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

6.2.6.

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

6.2.7.

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

6.2.8.

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

6.2.9.

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

6.2.10.

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

6.2.11.

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

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

6.2.12.

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

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

6.2.13.

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

6.2.14.

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

6.2.15.

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

6.2.16.

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

6.2.17.

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

6.2.18.

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

6.2.19.

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

6.2.20.

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

6.2.21.

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

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

6.2.22.

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

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

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial,

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.23.

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

Services of chiropractors and podiatrists are covered. Prevention, Health Promotion and Optional Treatment Services (EPSDT), private duty nursing services and genetic testing services are also covered.

Podiatrists’ services are limited to non-routine procedures; treatment of plantar warts, ingrown nails, ulcerations, bursitis, and infections; and minor surgery under local anesthetic. Some routine procedures are covered if there are complications due to foot pathology.

Genetic testing services are diagnostic or screening services to determine risk for genetic diseases.

6.2.24.

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

6.2.25.

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

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

6.2.26.

Enabling services (such as transportation, translation, and outreach services) (Section 2110(a)(27)) Transportation, translation, and outreach services are provided. Interpreter services consistent with Federal Medicaid EPSDT provisions are covered for non-English, limited English speaking and/or deaf/hard-of-hearing individual. Non-emergency medical transportation services are also provided under “enabling services”, for any health care service for which Medicaid will provide reimbursement with covered transportation services including: regional requirements with designated catchment area; mileage reimbursement for provider (agency) vehicles, to a family, to a volunteer driver, for an attendant; public transportation fare; wheelchair van services; highway tolls and parking fees; related travel expenses (i.e., necessity to stay overnight to receive medically necessary health care services); and seven day clinic services until such time as these services are covered by the Department under a Home and Community Based Waiver program (i.e., freestanding Methadone Clinics).

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

The State intends to claim the increased higher CHIP match rate (as authorized in CHIPRA) for the translation services they intend to provide, utilizing the State’s new payment system, Maine Integrated Health Management System (MIMHS). MIHMS payment is based upon provider's contracts and member's rate codes. There are different accounting strings set up for the rate codes/coverage codes and reimbursement methodologies outlined in contracts.

6.2.27.

Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28)) Rural health clinic services and other ambulatory services furnished by a rural health clinic, as well as federally qualified health center services are covered.

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

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

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

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

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

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

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

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

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

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

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

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

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

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

6.3.2.2- BH Tobacco cessation Provided for: Substance Use Disorder

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

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

6.3.2.3.1- BH Opioid Use Disorder

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 6.3.2.3.2- BH Alcohol Use Disorder

6.3.2.3.3- BH Other

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

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

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

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

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

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

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

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

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

6.3.4- BH

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

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

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

6.3.4.2- BH Detoxification Provided for: Substance Use Disorder

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

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

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

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

6.3.7- BH Care Coordination

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Provided for: Mental Health Substance Use Disorder

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

6.3.7.2- BH Care transition services Provided for: Mental Health Substance Use Disorder

6.3.8- BH Case Management Provided for: Mental Health Substance Use Disorder

6.3.9- BH Other Provided for: Mental Health Substance Use Disorder

6.4- BH Assessment Tools

6.4.1- BH Please specify or describe all of the tool(s) required by the state and/or each managed care entity:

ASAM Criteria (American Society Addiction Medicine) Mental Health Substance Use Disorders

InterQual Mental Health Substance Use Disorders

MCG Care Guidelines Mental Health Substance Use Disorders

CALOCUS/LOCUS (Child and Adolescent Level of Care Utilization System)

Mental Health Substance Use Disorders

CASII (Child and Adolescent Service Intensity Instrument) Mental Health Substance Use Disorders

CANS (Child and Adolescent Needs and Strengths) Mental Health Substance Use Disorders

State-specific criteria (e.g. state law or policies) (please describe)

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Mental Health Substance Use Disorders

Plan-specific criteria (please describe) Mental Health Substance Use Disorders

Other (please describe) Mental Health Substance Use Disorders

No specific criteria or tools are required Mental Health Substance Use Disorders

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools to determine possible treatments or plans of care, providing education, training, and technical resources, and covering the costs of administering or purchasing the assessment tools.

6.4.2- BH Please describe the state’s strategy to facilitate the use of validated assessment tools for the treatment of behavioral health conditions.

6.2.5- BH Covered Benefits The State assures the following related to the provision of behavioral health benefits in CHIP:

All behavioral health benefits are provided in a culturally and linguistically appropriate manner consistent with the requirements of section 2103(c)(6), regardless of delivery system.

The state will provide all behavioral health benefits consistent with 42 CFR 457.495 to ensure there are procedures in place to access covered services as well as appropriate and timely treatment and monitoring of children with chronic, complex or serious conditions.

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT1) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999) 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

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

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

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

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

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

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

6.2-DS

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

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

In the event that the State provides benefits through a group health plan or group health coverage, or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. (Formerly 8.6.) 6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

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

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

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

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements.

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

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

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT, the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3- MHPAEA.

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

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

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

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

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

6.2.3.1.1 MHPAEA The State assures that:

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

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

Yes No

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

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

6.2.3.2 MHPAEA The State assures that:

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

Annual and Aggregate Lifetime Dollar Limits

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

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

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

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

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

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

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

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as an attachment to the State child health plan.

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

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

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

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

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

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

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits. Guidance: The state’s methodology for calculating the average

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 limit for medical/surgical benefits must be consistent with 42 CFR 457.496(c)(4)(i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and results as an attachment to the State child health plan.

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

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits. Quantitative Treatment Limitations

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

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

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

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

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

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

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

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 health or substance use disorder benefits, the State assures:

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

Non-Quantitative Treatment Limitations

6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4)); (42 CFR 457.496(d)(5)) 6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

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

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

Yes No Guidance: The State can answer no if the State or MCE only provides out of network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

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

The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information 6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

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

State Managed Care entities Both Other

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

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

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

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

entities provide denial information:

State Managed Care entities Both

Other

Guidance: If other is selected, please specify the entity. 6.3. The State assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42 CFR 457.480)

6.3.1.

The State shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The State contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.6.2. (formerly 6.4.2) of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA. (Formerly 8.6.) (Section 2103(f)) Describe:

Guidance: States may request two additional purchase options in Title XXI: cost effective coverage through a community-based health delivery system and for the purchase of family coverage. (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4. Additional Purchase Options- If the State wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the State must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage- Payment may be made to a State in excess of the 10 percent limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the State to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The State may cross reference Section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42 CFR

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42 CFR 457.1005(b))

Guidance: Check below if the State is requesting to provide cost-effective coverage through a community-based health delivery system. This allows the State to waive the 10 percent limitation on expenditures not used for Medicaid or health insurance assistance if coverage provided to targeted low-income children through such expenditures meets the requirements of Section 2103; the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under Section 2103; and such coverage is provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Services Act or with hospitals such as those that receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923.

If the cost-effective alternative waiver is requested, the State must demonstrate that payments in excess of the 10 percent limitation will be used for other child health assistance for targeted low-income children; expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and other reasonable costs incurred by the State to administer the plan. (42 CFR, 457.1005(a))

6.4.1.3. The coverage must be provided through the use of a community based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42 CFR 457.1005(a))

Guidance: Check 6.4.2.if the State is requesting to purchase family coverage. Any State requesting to purchase such coverage will need to include information that establishes to the Secretary’s satisfaction that: 1) when compared to the amount of money that would have been paid to cover only the children involved with a comparable package, the purchase of family coverage is cost effective; and 2) the purchase of family coverage is not a substitution for coverage already being provided to the child. (Section 2105(c)(3)) (42 CFR 457.1010)

6.4.2.

Purchase of Family Coverage- Describe the plan to purchase family coverage.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Payment may be made to a State for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42 CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective. The State’s cost of purchasing family coverage, including administrative expenditures, that includes coverage for the targeted low-income children involved or the family involved (as applicable) under premium assistance programs must not be greater than the cost of obtaining coverage under the State plan for all eligible targeted low-income children or families involved; and (2) The State may base its demonstration of cost effectiveness on an assessment of the cost of coverage, including administrative costs, for children or families under premium assistance programs to the cost of other CHIP coverage for these children or families, done on a case-by-case basis, or on the cost of premium assisted coverage in the aggregate.

6.4.2.2. The State assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42 CFR 457.1010(b))

6.4.2.3. The State assures that the coverage for the family otherwise meets title XXI requirements. (42 CFR 457.1010(c))

6.4.3-PA: Additional State Options for Providing Premium Assistance (CHIPRA # 13, SHO # 10-002 issued February, 2, 2010) A State may elect to offer a premium assistance subsidy for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(B), to all targeted low-income children who are eligible for child health assistance under the plan and have access to such coverage. No subsidy shall be provided to a targeted low-income child (or the child’s parent) unless the child voluntarily elects to receive such a subsidy. (Section 2105(c)(10)(A)). Please remember to update section 9.10 when electing this option. Does the State provide this option to targeted low-income children?

Yes

No

6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance Subsidy

6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored insurance meets the definition of qualified employer-sponsored coverage as defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(C).

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 6.4.3.1.2-PA Describe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee’s employer.

6.4.3.2-PA: Supplemental Coverage for Benefits and Cost Sharing Protections Provided under the Child Health Plan.

6.4.3.2.1-PA If the State is providing premium assistance for qualified employer- sponsored coverage, as defined in Section 2105(c)(10)(E)(i), provide an assurance that the State is providing for each targeted low-income child enrolled in such coverage, supplemental coverage consisting of all items or services that are not covered or are only partially covered, under the qualified employer-sponsored coverage consistent with 2103(a) and cost sharing protections consistent with Section 2103(e).

6.4.3.2.2-PA Describe whether these benefits are being provided through the employer or by the State providing wraparound benefits.

6.4.3.2.3-PA If the State is providing premium assistance for benchmark or benchmark-equivalent coverage, the State ensures that such group health plans or health insurance coverage offered through an employer will be certified by an actuary as coverage that is equivalent to a benchmark benefit package described in Section 2103(b) or benchmark equivalent coverage that meets the requirements of Section 2103(a)(2).

6.4.3.3-PA: Application of Waiting Period Imposed Under State Plan: States are required to apply the same waiting period to premium assistance as is applied to direct coverage for children under their CHIP State plan, as specified in Section 2105(c)(10)(F).

6.4.3.3.1-PA Provide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State has a waiting period in place for children in direct CHIP coverage).

6.4.3.4-PA: Opt-Out and Outreach, Education, and Enrollment Assistance

6.4.3.4.1-PA Describe the State’s process for ensuring parents are permitted to disenroll their child from qualified employer-sponsored coverage and to enroll in CHIP effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child (Section 2105(c)(10)(G)).

6.4.3.4.2-PA Describe the State’s outreach, education, and enrollment efforts related to premium assistance programs, as required under Section 2102(c)(3). How does the State inform families of the availability of premium assistance, and assist them in obtaining such subsidies? What are the specific significant

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan? (Section 2102(c))

6.4.3.5-PA Purchasing Pool- A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool (Section 2105(c)(10)(I)). Does the State provide this option?

Yes

No

6.6.3.5.1-PA Describe the plan to establish an employer-family premium assistance purchasing pool.

6.6.3.5.2-PA Provide an assurance that employers who are eligible to participate: 1) have less than 250 employees; 2) have at least one employee who is a pregnant woman eligible for CHIP or a member of a family that has at least one child eligible under the State’s CHIP plan.

6.6.3.5.3-PA Provide an assurance that the State will not claim for any administrative expenditures attributable to the establishment or operation of such a pool except to the extent such payment would otherwise be permitted under this title.

6.4.3.6-PA Notice of Availability of Premium Assistance- Describe the procedures that assure that if a State provides premium assistance subsidies under this Section, it must: 1) provide as part of the application and enrollment process, information describing the availability of premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to ensure that parents are fully informed of the choices for child health assistance or through the receipt of premium assistance subsidies (Section 2105(c)(10)(K)).

6.4.3.6.1-PA Provide an assurance that the State includes information about premium assistance on the CHIP application or enrollment form.

Section 7. Quality and Appropriateness of Care

Guidance: Methods for Evaluating and Monitoring Quality- Methods to assure quality include the application of performance measures, quality standards consumer information strategies, and other quality improvement strategies.

Performance measurement strategies could include using measurements for external reporting either to the State or to consumers and for internal quality improvement purposes. They could be based on existing measurement sets that have undergone rigorous evaluation for their appropriateness (e.g., HEDIS). They may include the use of standardized member satisfaction surveys (e.g., CAHPS) to assess members’

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 experience of care along key dimensions such as access, satisfaction, and system performance.

Quality standards are often used to assure the presence of structural and process measures that promote quality and could include such approaches as: the use of external and periodic review of health plans by groups such as the National Committee for Quality Assurance; the establishment of standards related to consumer protection and quality such as those developed by the National Association of Insurance Commissioners; and the formation of an advisory group to the State or plan to facilitate consumer and community participation in the plan.

Information strategies could include: the disclosure of information to beneficiaries about their benefits under the plan and their rights and responsibilities; the provision of comparative information to consumers on the performance of available health plans and providers; and consumer education strategies on how to access and effectively use health insurance coverage to maximize quality of care.

Quality improvement strategies should include the establishment of quantified quality improvement goals for the plan or the State and provider education. Other strategies include specific purchasing specifications, ongoing contract monitoring mechanisms, focus groups, etc.

Where States use managed care organizations to deliver CHIP care, recent legal changes require the State to use managed care quality standards and quality strategies similar to those used in Medicaid managed care.

Tools for Evaluating and Monitoring Quality- Tools and types of information available include, HEDIS (Health Employer Data Information Set) measures, CAHPS (Consumer Assessments of Health Plans Study) measures, vital statistics data, and State health registries (e.g., immunization registries).

Quality monitoring may be done by external quality review organizations, or, if the State wishes, internally by a State board or agency independent of the State CHIP Agency. Establishing grievance measures is also an important aspect of monitoring.

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 8.

Guidance: The State must specify the qualifications of entities that will provide coverage and the conditions of participation. States should also define the quality standard they are using, for example, NCQA Standards or other professional standards. Any description of the information strategies used should be linked to Section 9. (Section 2102(a)(7)(A)) (42 CFR 457.495)

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 care, and immunizations provided under the plan. (Section 2102(a)(7)(A)) (42 CFR 457.495(a)) Will the State utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1.

Quality standards

Performance measurements developed by the MaineCare Services as part of Utilization Reporting and the Primary Care Physician Incentive Payment program (discussed in detail Section 7.1.2) were modeled on both national (NCQA) standards and standards developed specifically for the State of Maine.

The MaineCare Services has also adopted the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents to assure quality and appropriateness of care with respect to well-baby care, well- child and adolescent care and administration of age appropriate immunizations. The MaineCare Services have developed and made available Well Child Visit forms that contain age appropriate periodicity schedules for well-child checks and immunizations to providers. These forms serve many purposes including, but not limited to:

 Serves as reminder for primary care providers on age appropriate screening services;  May serve as the provider’s medical record, provided it is complete;  Provides MaineCare with information about needed follow-up services that can be provided by MaineCare Member Services.

7.1.2.

Performance measurement

The MaineCare Services uses two primary means of monitoring and providing feedback to providers regarding performance: a Utilization Report and the Primary Care Physician Incentive Payment report. The Utilization Report is distributed to primary care physicians on a quarterly basis and contains performance measures centered on well-child care, utilization of emergency services, potentially avoidable hospitalizations for chronic/serious medical conditions, and other disease prevention measures. The report, broken down by specialty, presents a comparison of provider groups against other statewide providers across all performance measures. The Primary Care Physician Incentive Payment report contains additional performance measures focused on preventive indicators and is used for purposes of provider education and determining incentive payments.

MaineCare Services has an incentive program designed to improve health outcomes through management of drug utilization. The Physician Directed Drug Initiative provides incentive payments to providers based on

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 measures of peer performance for certain relevant desired drug outcomes/medical conditions (e.g., increase in percentage of CAHF patients on ACEI); peer performance for medical outcomes related to these medical conditions (e.g., maintain/reduce hospital/ER visits for CAHF patients); and peer performance for medical outcomes across all medical conditions aggregated together (e.g., total hospitalization rates, length of stay, readmission rates/ER rates).

MaineCare Services also reports on well-child visits, Chlamydia screening rates, ER use, lead screening and dental services as part of the CHIP Annual Report. MaineCare is a joint recipient of a Federal grant, funded through CHIPRA called Improving Health Outcomes for Children. One of the primary goals of the grant is to obtain data on health metrics to improve child health. For the 2011 CHIP Annual Report, Maine plans to report on all measures that can be collected through claims data. The report will also include progress on work to determine how to collect those measures not available through claims data. In addition to the CHIPRA measures that are requested in the CHIP Annual report, the Maine pediatric provider community has developed 23 additional measures to indicate that children are receiving recommended preventive care, screening and treatment. Some of those measures are also claims based and will be included in the report as well. The report will also include information on plans for how measures sourced from registry or electronic health data may be collected and reported in future CHIP Annual reports.

The MaineCare Services also routinely monitors complaints and grievances received from members, provider transfer rates, provider caseload size and 24 hour coverage by primary care providers. Complaints and grievances are monitored for trends and required interventions and/or follow-up. Provider transfer rates (members transferring out of a particular practice) and caseload sizes are also monitored on a regular basis to determine whether intervention is required. Each primary care provider is also monitored once a year to ensure that each practice is providing the requisite 24 hour coverage for MaineCare members.

7.1.2 (a) CHIPRA Quality Core Set

7.1.2 (b) Other

7.1.3.

Information strategies

Within 30 days of enrollment, each MaineCare and CHIP member is sent a mailing containing the informing letter, as required by EPSDT, and information describing covered services, locating providers, available assistance for scheduling visits and transportation, etc. Member Services will provide the member with requested assistance and will also provide

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 information on statewide resources available for non-covered services. A Resource Guide is maintained and updated regularly and contains resources available on health and social services in the State, broken down by county.

The “MaineCare listserv” is a listserv providers can sign up for and contains program/clinical information.

When appropriate, follow-up with the member may be provided by Member Services and, if needed, by Public Health Nurses. For example, a member may be provided with assistance locating transportation to the doctor’s office for well-child checks or in obtaining follow-up treatment recommended by health care providers.

MaineCare Services also provides member education on inappropriate use of the emergency room. On an ongoing basis, MaineCare Services receives information from hospitals on avoidable emergency room use. MaineCare partners with providers to reach out to members and assist with any barriers to accessing care in an appropriate setting that may exist (such as transportation). For example, members may not be aware that their primary care provider is available 24 hours or the provider may not have been available and intervention is needed with the provider.

7.1.4.

Quality improvement strategies

A primary quality improvement strategy used by MaineCare Services to ensure access to well-baby/child/adolescent care and immunizations is the use of Bright Futures standard of care by MaineCare providers. The Well Child Visit forms were refined with input from pediatricians and other primary care physicians in the State and based on Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. Each primary care provider participating with MaineCare who has signed an EPSDT Rider to the provider/supplier agreement is required to use the Bright Futures standard of care. Each Well Child Visit form contains age- appropriate health measures and immunizations and is used for children from birth through age 18. Many providers have used the forms as a basis for development of electronic health record systems.

The Well Child Visit forms are also used by providers and MaineCare Services to provide members with any needed assistance to comply with treatment plans, e.g., assistance with accessing follow-up treatment or diagnostic testing. The forms are reviewed by Department nursing staff on a daily basis for requested follow-up with the member. Forms are then shared with EPSDT staff for actual follow-up with the family. Once follow-up has occurred, notification is sent to the provider. As providers are moving toward electronic health records and incorporating Bright

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 Futures into them, the mechanism for referral and follow-up may be updated.

DHHS continues to focus efforts in the following areas:

 Reporting pediatric quality measures to payers, providers and consumers.

 Designing, developing and implementing HIT linkages and systems within the Maine Department of Health and Human Services and with medical practices and health systems to collect and report EPSDT/Bright Futures preventive measures and other clinical data from the clinical record.

 Designing, implementing and evaluating an electronic health assessment for children in Maine’s child welfare foster care system.

 Implementing the Bright Futures Resource Toolkit with Maine child health providers and assessing the impact on the provision of EPSDT services in Maine.

 Building a coalition around child health quality improvement in Maine.

 MaineCare Services also furnishes providers (as is noted in Section 7.1.2) with information on emergency room visit rates for his/her practice to enable the provider to address the issue of inappropriate use of the emergency room with his/her patients.

Guidance: Provide a brief description of methods to be used to assure access to covered services, including a description of how the State will assure the quality and appropriateness of the care provided. The State should consider whether there are sufficient providers of care for the newly enrolled populations and whether there is reasonable access to care. (Section 2102(a)(7)(B))

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

7.2.1. Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42 CFR 457.495(a)) Please see sections 7.1.1-1.1.4. 7.2.2. Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42 CFR 457.495(b)) Please see sections 7.1.1-1.1.4.

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 7.2.3. Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of- network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42 CFR 457.495(c)) One method used to monitor and enhance treatment of members with chronic/serious medical conditions is the use of the Utilization Report provided to primary care providers. As is noted in Section 7.1.2., the Utilization Report, provided to each primary care provider on a quarterly basis, contains information on potentially avoidable hospitalizations for particular chronic/serious medical conditions. The information presents a comparison of the particular PCP’s practice against other statewide providers in the same specialty (admission rates per 1000 MaineCare members per year). The report also contains a listing of the particular MaineCare members on the PCP’s panel currently hospitalized with the identified conditions.

MaineCare managed care members in need of treatment by specialists may access care through referral from the member’s Primary Care Provider for those covered MaineCare services designated as ‘managed’ services. For those MaineCare services that do not require PCP authorization, members may self-refer or seek prior authorization from MaineCare Services.

Prior authorization is required for certain MaineCare covered services obtained in-state and all MaineCare covered services provided out-of-state (with the exception of emergency services and services furnished by providers located within 15 miles of the New Hampshire border and 5 miles of Canadian border who are treated as in-state providers). Prior authorization for covered services rendered out-of-state is provided only when a member’s continuity of care must be preserved for medical reasons and only after it is determined that the needs of the member cannot be met in the State of Maine.

Another management tool developed and used by the MaineCare Services to monitor and manage MaineCare members with chronic pain is the Pain Management Program. Members receiving 3-5 narcotics from different prescribers or 6+ different narcotics are invited to voluntarily join the program. Under the program, members are matched with one physician responsible for managing all medication use by the member with patient safety as a primary focus.

7.2.4. Decisions related to the prior authorization of health services are completed in accordance with State law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42 CFR 457.495(d)) Exigent medical circumstances may require more rapid response according to the medical needs of the patient.

Prior authorization of health services are completed in accordance with MaineCare

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 requirements Section 8. Cost-Sharing and Payment

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

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

8.1.1.

Yes 8.1.2.

No, skip to question 8.8.

8.1.1-PW

Yes 8.1.2-PW

No, skip to question 8.8.

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

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

CHIP Disaster Relief:

At State discretion, premiums may be temporarily waived for CHIP applicants and/or existing beneficiaries who reside and/or work in a State or Federally declared disaster area.

8.2.1.

Premiums:

Below 158% FPL – no premium;

158% to 166% FPL – premiums are $8 per month for the first child and $16 per month for 2 or more children;

167% to 177% FPL- premiums are $16 per month for the first child and $32 per month for 2 or more children;

178% to 192% FPL- premiums are $24 per month for the first child and $48 per month for 2 or more children;

193% to 208% FPL- premiums are $32 per month for the first child and $64

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 per month for 2 or more children;

CHIP Disaster Relief: At State discretion, non-payment of premiums may be temporarily forgiven/waived for CHIP applicants and/or existing beneficiaries who reside and/or work in a State or Federally declared disaster area.

8.2.2.

Deductibles:

Not applicable.

8.2.3.

Coinsurance or copayments:

Not applicable.

8.2.4.

Other:

8.2-DS

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

8.2.1-DS Premiums:

8.2.2-DS Deductibles:

8.2.3-DS Coinsurance or copayments:

8.2.4-DS Other:

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

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

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

8.4.1.

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

No cost-sharing applies to well-baby and well-child care, including age-

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3

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

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

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

8.4.3- MHPAEA Cost sharing applied to benefits provided under the State child health plan will remain capped at five percent of the beneficiary’s income as required §457.560 (§457.496(d)(i)(D)).

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

Yes (Specify: ) No Guidance: If the state does not apply financial requirements on any mental health or substance use disorder benefits, the state meets parity requirements for financial requirements. If the state does apply financial requirements to mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue below.

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

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

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

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above (Section 6.2.5.2) for each classification or within which the State applies financial requirements to mental health or substance use disorder benefits (§457.496(d)(3)(i)(E)). Guidance: Please include the state’s methodology as an attachment to the State child health plan.

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

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

8.4.8- MHPAEA For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State must determine the predominant level (as defined in §457.496(d)(3)(i)(B)(1)) of that type which is applied to medical/surgical benefits in the classification. For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State assures:

The same reasonable methodology applied in determining the dollar amounts used in determining whether substantially all medical/surgical benefits within a classification are subject to a type of financial requirement also is applied in determining the dollar amounts used to determine the predominant level of a type of financial requirement applied to medical/surgical benefits within a classification. (§457.496(d)(3)(i)(E)) The level of each type of financial requirement applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominate level of that type which is applied by the State to medical/surgical benefits within the same classification. (§457.496(d)(2)(i)) Guidance: If there is no single level of a type of financial requirement that exceeds the one-half threshold, the State may combine levels within a type of financial requirement such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominate level is the least restrictive level of the levels combined to meet the one-half threshold

ME-20-0027 Approval Date: October 18, 2021 Effective Date: October 1, 2020 (§457.496(d)(3)(i)(B)(2)).

8.5. Describe how the State will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the State for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

As shown in the following table, the premium is never higher than the equivalent of .9% of family income for those at the lowest end of the FPL range. Premium as a % of Benefit Cost* Monthly Premium Cost Minimum Monthly Income** Premium as a % of Minimum Income*** No. of Children 1 2 1 2 1 2 1 2 FPL: 158% - 166% 5% 10% $8 $16 $1550 $2098 0.6% 0.9% 167% - 177% 10% 20% $16 $32 $1638 $2218 1.1% 1.6% 178% - 192% 15% 30% $24 $48 $1746 $2364 1.6 % 2.3% 193% - 208% 20% 40% $32 $64 $1893 $2563 1.9% 2.8%

* Based on an estimate annual benefit cost of $1920 per child or $160 monthly

** Minimum monthly income corresponds to 158% (for 158% - 166%), 167% (for 167% - 177%), 178% (for 178% - 192%) and 193% (for 193% - 208%) of 2015 FPL

*** The premiums as a % of minimum income will change (lower) when we adjust for the annual FPL increase.

8.6. Describe the procedures the State will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535) As noted in Section 4.4.5, any eligible child who is American Indian or Alaskan Native is enrolled in MaineCare under Title XIX or Title XXI and treated as any other eligible child, with the exception that the child is not required to pay a premium or other cost sharing. On the application form, there is a specific question that asks applicants whether they are American Indian or Alaskan Native and informs them that American Indians and Alaskan Native don’t have to pay premiums. If an applicant checks this box and is enrolled in MaineCare, the Department does not generate premium coupons for the member.

8.7. Provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c)) Premiums must be paid at the beginning of each month for coverage for that month.