DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203 CfNER5 for MEDIGIRE & MED/U1/DSERWCE5 Division of Medicaid and Children's Health Onerations / Boston Regional Office December 15,2009 Brenda M. Harvey, Commissioner Department of Health and Human Services 11 State House Station Augusta, Maine 04333-00 1 1 Dear Ms. Harvey: We are pleased to enclose a copy of approved State plan amendment (SPA) No. 09-008. This SPA is effective July 1,2009 as requested. SPA 09-008 transmitted a proposed amendment to your approved Title XIX State plan to elect the option provided by $214 of the Children's Health Insurance Program Reauthorization Act of 2009, Public Law 11 1-3. This option provides States, at their option, to grant full Medicaid coverage to all otherwise eligible alien children or pregnant women fully residing in the United States. We are approving this SPA as revised. As we agreed to, you submitted the latest revised draft version of the State plan pages. In addition, we added 5 1903(v)(4) of the Social Security Act in box 6 of the Transmittal and Notice of Approval of State Plan Material (CMS-179). Furthermore, we revised boxes 8 and 9 to indicate the correct page number of the plan attachment and the page number of the superseded plan attachment, respectively. Please contact Chong Tieng if there are questions. He can be reached at (61 7) 565-91 57. Sincerely, Richard R. McGreal Associate Regional Administrator Enclosure cc: Tony Marple, Director, Office of MaineCare Services

Revision: CMS-PM- OMB No.: ATTACHMENT 2.6-A Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Maine ELIGIBILITY CONDITIONS AND REQUIREMENTS Citation(s1 Condition or Requirement 42 CFR 435.406 3. Is residing in the United States (U.S.), and-- a Is a citizen or national of the United States; b. Is a qualified alien (QA) as defined in section 43 1 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) as amended, and the QA's eligibility is required by section 402(b) of PRWORA as amended, and is not prohibited by section 403 of PRWORA as amended; c. Is a qualified alien subject to the 5-year bar as described in section 403 of PRWORA, so that eligibility is limited to treatment of an emergency medical condition as defined in section 401 of PRWORA; d. Is a non-qualified alien, so that eligibility is limited to treatment of an emergency medical condition as defined in section 401 of PRWORA; e. Is a QA whose eligibility is authorized under section 402(b) of PRWORA as amended, and is not prohibited by section 403 of PRWORA as amended. x State covers all authorized QAs. - State does not cover authorized QAs. - f State elects CHIPRA option to provide full Medicaid coverage to otherwise eligible pregnant women or children as specified below who are aliens lawfilly residing in the United States; including the following: TN No: 09-008 Approval Date: 1211 5/09 Supersedes TN NO: 91-014 Effective Date: 07/01 I09

Revision: CMS-PM- OMB No.: ATTACHMENT 2.6-A Page 2a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State ELIGIBILITY CONDITIONS AND REQUIREMENTS Citation(s1 Condition or Requirement (1) A "Qualified alien" otherwise subject to the 5-year waiting period per section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996; (2) A citizen of a Compact of Free Association State (i.e., Federated States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau) who has been admitted to the U.S. as anon- immigrant and is permitted by the Department of Homeland Security to reside permanently or indefmitely in the U.S.; (3) An individual described in 8 CFR section 103.12(a)(4) who does not have a permanent residence in the country of their nationality and is in a status that permits the individual to remain in the U.S. for an indefinite period of time, pending adjustment of status. These individuals include: (a) An individual currently in temporary resident status as an Amnesty beneficiary pursuant to section 21 0 or 245A of the Immigration and Nationality Act (INA); (b) An individual currently under protected Status pursuant to section 244 of the INA; TN No: 09-008 Supersedes TN No: NEW Approval Date: 1211 5/09 Effective Date: 07/01 I09

Revision: CMS-PM- OMB No.: ATTACHMENT 2.6-A Page 2b STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State ELIGIBILITY CONDITIONS AND REQUIREMENTS Citation(s1 Condition or Reauirement (c) A family Unity beneficiary pursuant to section 301 of Public Law 101 - 649 as amended by, as well as pursuant to, section 1504 of Public Law 106-554; (d) An individual currently under Deferred Enforced Departure pursuant to a decision made by the President; and (e) An individual who is the spouse or child of a U.S. citizen whose visa petition has been approved and who has a pending application for adjustment of status; and (4) An individual in non-immigrant classifications under the INA who is remain in the U.S. for an indefinite period, including the following as specified in section 101 (a)(15) of the INA: A parent or child of an individual with special immigrant status under section 101 (a)(27) of the INA, as permitted under section 101 (a)(15)(N) of the INA; A Fianck of a citizen, as permitted under section 101 (a)(l5)(K) of the INA; A religious worker under section 101 (a)(15)(R); An individual assisting the Department of Justice in a criminal investigation, as permitted under section lOl(a)(l5)(S) of the INA; A battered alien under section 101 (a)(15)(U) (see also section 43 1 as amended by PRWORA); and An individual with a petition pending for 3 years or more, as permitted under section 101 (a)(15)(V) of the INA. TN NO: 09-008 Supersedes TN No: Approval Date: 12/15/09 Effective Date: 07/01 I09

Revision: CMS-PM- OMB No.: ATTACHMENT 2.6-A Page 2c STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State ELIGIBILITY CONDITIONS AND REQUIREMENTS Citation(s) Condition or Requirement x Elected for pregnant women. -- x Elected for children under age 21 . - g. -x The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA section 2 14 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 lawhlly 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 fiom the information readily available, it must require the individual to provide documentation or firther evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1 1 37(d) of the Act. TN NO: 09-008 Supersedes TN No: NEW Approval Date: 1211 5/09 Effective Date: 07/01 109

STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 093801 93 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMllTAL NUMBER: TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION 2. STATE: 0 9 - - 0 0 8 I 4. PROPOSED EFFECTIVE DATE(S) JULY 1,2009 MAINE DEPARTMENT OF HEALTH AND HUMAN SERVICES I 5. TYPE OF PLAN MATERIAL (CHECK ONE): 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL 0 NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 1 7. FEDERAL BUDGET IMPACT: Section 214 of the CHIPRA Section 1903 (v) (4) of t h e Act a.FFY 09 $ $7,006,993 b. FFY 10 $ $7.102.343 10. SUBJECT OF AMENDMENT: OPTION TO COVER 5-YEAR BAR PREGNANT WOMEN AND CHILDREN UNDER AG 21 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 4T74Q63ENf L?@A( f~%.k17 At@M!d Attachment 2.6-A, pages 2-2c 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 2.6-A, page 2 dk+llddds' BA$k5Hd$Ad$Wdd 1 1. GOVERNOR'S REVIEW (Check One): GOVERNOR'S OFFICE REPORTED NO COMMENT X u OTHER, AS SPECIFIED COMMENTS OF GOVERNOR'S OFFICE ENCLOSED COMMISSIONER, DEPT. OF HUMAN SERVICES NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMllTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: I 13. TYPED NAME: BRENDA M. HARVEY Decem 16. RETURN TO: ANTHONY MARPLE Office of MaineCare Services 14. TITLE: COMMISSIONER, DEPARTMENT OF HEALTH AND HUMAN SERVICES 15. DATE SUBMITTED: September 16, 2009 'LAN APP #I 1 State House Station 442 Civic Center Drive Augusta, ME 04333-001 1 'ROVED - - FOR REGIONAL OFFICE USE ONLY -E RECEI\""' I 7. DATE APPROVEn. ~ b e r 15 ,HED ONE COF I q 'Y ATTAC ECTIVE DATE OF APPROVED MATER u 'ED NAME I. TITLE A ~ s o c i a t ; ' ~ e g i o n a l Admini r l i v i s i o n of Medicaid and C h i l d r e n ' s n e a l t h 23. REL We r e v i s e u u u n e s o auu and page . of t h e t o a d d ' a ; ' ! s t a t u indicate ~ l l e a v v r u v r l a c e v a r e llul~luer s U L . cue v ~ a l l ~ L L ~ L L I I I I ~ number Federal seded p i t a t i o n l a n a t . . . .. tachmer ~ t , r e s u pectivr I box 6 a l s o : revised super: t o r y c: FORM HCFA-179 (07-92) Instructions on Back /s/

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203 CEMTRS for MFD/CQRE & MFDIUIID SERYCFS Division of Medicaid and Children's Health Operations/ Boston Regional Office May 19,2010 Brenda M. Harvey, Commissioner Department of Health and Human Services 11 State House Station Commissioner's Office Augusta, Maine 04333-00 1 1 Dear Ms. Harvey: We are pleased to enclose a copy of approved State plan amendment (SPA) No. 10-003. This SPA is effective January l,20 10. SPA 10-001 transmitted a proposed amendment to your Agency's approved Title XIX State plan to reflect the changes enacted by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Section 1 15 of MIPPA requires States to exempt Medicare cost-sharing benefits paid under the Medicare saving programs (MSP) from estate recovery under section 191 7(b)(l) of the Social Security Act (the Act). The intent of this provision is to encourage dual eligible beneficiaries to more fully utilize Medicare cost-sharing benefits available through the MSPs and allay concerns that Medicaid estate recovery will, after their death, lay claim to recover the value of these cost-sharing benefits from their estate. This provision was effective January 1, 201 0. Please note that as agreed to by your staff, the effective date of the SPA was changed from April 1,20 10 to January 1,20 10 to comply with 5 1 15 of MIPPA. We reviewed this SPA for compliance with 51902(a)(73) of the Act as added by §5006(e) of the American Recovery and Reinvestment Act of 2009, Public Law 1 1 1-5. We determined that this SPA would benefit all Medicaid beneficiaries including members of Federally recognized tribes. We ask that your Department inform the Federally recognized tribes in your state of the changes brought forth by 5 1 15 of MIPPA. Please note that we approved this SPA as revised. Per agreement with your staff, we added the statutory citation, "section 191 7(b)(l) of the Social Security Act" in box 6 of the Transmittal and Notice of Approval of State Plan Material (CMS-179). We also revised box 15 to indicate the actual date the SPA was submitted. Further, we indicate in box 17 that the proposed effective date was revised to January 1,20 10 as agreed to by your staff.

Page 2 - Brenda M. Harvey, Commissioner If there are questions, please contact Chong Tieng. He can be reached at (617) 565-91 57. Sincerely, Is/ Richard R. McGreal Associate Regional Administrator

Revision: HCFA-PM-95-3 (MB) May 1995 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT StateITerritory: Maine (b) Adiustment or Recoveries (continued) (3) Continued Limitations on Estate Recovery - Medicare Cost Sharing: (i) Medical assistance for Medicare cost sharing is protected from estate recovery for the following categories of dual eligibles: QMB, SLMB, QI, QDWI, QMB+, SLMB+. This protection extends to medical assistance for four Medicare cost sharing benefits: (Part A and B premiums, deductibles, coinsurance, co-payments) with dates of service on or after January l,20 10. The date of service for deductibles, coinsurance, and co-payments is the date the request for payment is received by the State Medicaid Agency. The date of service for premiums is the date the State Medicaid Agency paid the premium. (ii) In addition to being a qualified dual eligible the individual must also be age 55 or over. The above protection from estate recovery for Medicare cost sharing benefits (premiums, deductibles, coinsurance, co- payments) applies to approved mandatory (i.e., nursing facility, home and community- based services, and related prescription drugs and hospital services) as well as optional Medicaid services identified in the State plan, which are applicable to the categories of duals referenced above. TN No.: 10-003 Supersedes Approval Date: 0511 911 0 Effective Date: 01/01/10 TN No.: N/A

5. TYPE OF PLAN MATERIAL (CHECK ONE): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN a AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 2. STATE: MAINE TRANSMITTAL AND NOTlCE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMllTAL NUMBER: 10 -- 003 SUBJECT OF AMENDMENT: LIMITATIONS ON ESTATE RECOVERY 1 1. GOVERNOR'S REVIEW (Check One): [7 GOVERNOR'S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED [7 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED COMMISSIONER, DEPT. OF HUMAN SERVICES FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 433.36 Section 1917 (h) (1) o f t h e

Sec-t 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: PAGE 53A-1 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE@) APRIL 1,201 0 7. FEDERAL BUDGET IMPACT: a. FFY - 10 Cost Neutral b. FFY 11 Cost Neutral 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): NOT APPLICABLE 12. SIGNATURE OF STATE AGENCY OFFICIAL: m . I 1 16. RETURN TO: Commissioner, Maine Department of Health and Human I #I 1 State House Station 13. TYPED NAME: BRENDA HARVEY 14. TITLE: ANTHONY MARPLE Director, Office of MaineCare Services 'ED: 2010 Services 15. DATE SUBMITTED: ~ P P ( ~ ~ , ~ f l March 29, 2010 LAN APPROVED - ONE COPY ATACHED 442 CIVIC CENTER DRIVE Augusta, ME 04333-001 1 19. EFFl Jan1 CnD D5GIONAL OFFICE USE ONLY - - 1 18. DATE APPROVE[ ATE OF P 2010 D MATER IAL: 21. TYPtIJ NAMt TIT1 'Associate Regional Adminisrraror, ) ' c : ~ o a ~ + :at ions Ricl 23. REM hilrlrpr Oper A s z box i n 1: t o by ! indicat hould I jtate s :e the )e r e v i t a f f , \ actual - - 3 - - atutorj was st 010. c i t a t tbmitte We a: sed ef: ge added a st< date the SPA sea LO January 1, 21 ion i n box 6. d. The propo Lso rev Eective /s/

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services CAA S JFK Federal Building, Government Center

Room 2275 CENTERS for MEDICARE & MEDICAID SERVICES

Boston, Massachusetts 02203

Division of Medicaid and Children's Health Operations / Boston Regional Office

July 9, 2010

Brenda M. Harvey, Commissioner Department of Health and Human Services 11 State House Station

Augusta, Maine 04333-0011

Dear Ms. Harvey:

We are pleased to enclose a copy of approved State plan amendment (SPA) No. 10-005. This SPA is effective April 1, 2010 as requested.

This SPA transmitted an amendment to your approved Title XIX State plan to comply with the requirements of §112 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), P.L. 110-275. This provision amends §1905(p)(1)(C) of the Social Security Act (the Act) to make the resource limit for Qualified Medicare Beneficiaries (QMB), Specified Low- Income Medicare Beneficiaries (SLMB) and Qualified Individuals (QI) conform to the resource limit for individuals who qualify for the full subsidy Medicare Part D low-income subsidy. It requires States to increase the resource exemption for individuals eligible as QMBs, SLMBs and Qls to three times the resource limits of the Supplemental Security Income (SSI) program. Prior to MIPPA, the resource exemption was twice the SSI limit.

We are approving this SPA as revised. As agreed to by your staff, we removed the text that begins “the State applies more restrictive eligibility standards...” from Attachment 2.2-A,

page 9a and renumbered the page as page 9b. On item 25 of the newly number page 9b, we removed the statutory citation “1860D-14(a)(3)(D) of the Act”. We renumbered the page 9b

in the original submission to page 9b1. We moved the text on page 9c to page 9b1. We deleted page 9c from the proposed SPA. On item 9 to page 22a to Attachment 2.6-A, we eliminated the statutory citation “1860D-14(a)(3)(D) of the Act”.

With respect to the Transmittal and Notice of Approval of State Plan Material (CMS-179), we added the statutory citations “1902(a)(10)(E)(i)-(iv), 1905(p)(3) and 1860D-14(a)(3)(D)” in box 6. We also revised box 8 to reflect the correct page numbers of the attachment.

Page 2 - Brenda M. Harvey, Commissioner

We reviewed this SPA for compliance with §1902(a)(73) of the Act as added by §5006(e) of the American Recovery and Reinvestment Act of 2009, Public Law 111-5. We determined that this SPA would benefit all Medicaid beneficiaries and providers including members of federally recognized tribes and Indian Health Services contract health services providers. We ask that your Department inform the federally recognized tribes in your state of the changes brought forth by the Recovery Act and this SPA.

If there are questions, please contact Chong Tieng. He can be reached at (617) 565-9157. Sincerely, /s/ Richard R. McGreal Associate Regional Administrator Enclosure

ce: Tony Marple, Director, Office of MaineCare Services

Revision: ATTACHMENT 2.6-A Page 22 State: Maine Citation Condition or Requirement

Resource Standard - Medically Needy

a. Resource standards are based on family size. 1902(a)(10)(C)(i) b. A single standard is employed in determining resource of the Act resource eligibility for all groups.

1902(a)(10)(E), 1905(p)(1)(D), 1905(p)(2)(B) and 1860D-14(a)(3)(D)

of the Act

c. In 1902(f) States, the resource standards are more restrictive than in 7.b. above for--

__ Aged __ Blind __ Disabled

Supplement 2 to ATTACHMENT 2.6-A specifies the resource standards for all covered medically needy groups. If the agency chooses more restrictive levels under 7.c., Supplement 2 to ATTACHMENT 2.6-A so indicates.

Resource Standard - Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries and Qualifying Individuals

For Qualified Medicare Beneficiaries covered under section 1902(a)(10)(E)(i) of the Act, Specified Low-Income Medicare Beneficiaries covered under section 1902(a)(10)(E)(iii) of the Act, and Qualifying Individuals covered under 1902(a)(10)(E)(iv) of the Act, the resource standard is three times the SSI resource limit, adjusted annually since 1996 by the increase in the consumer price index.

TN No: _10-005 Supersedes TN No. 91-014

Approval Date 7A hie Effective Date: 04/01/10

Revision: ATTACHMENT 2.6-A Page 22a

State: _Maine

Citation Condition or Requirement

1902(a)(10)(E)(ii), 1905(s) 9. Resource Standard - Qualified Disabled and Working For qualified disabled and working individuals covered under section 1902(a)(10)(E)(ii) of the Act, the resource standard for an individual or a couple (in the case of an individual with a spouse) is two times the SSI resource limit.

1902(u) of the Act 10. For COBRA continuation beneficiaries, the resource standard is:

__ Twice the SSI resource standard for an individual. __ More restrictive standard as applied under section

1902(f) of the Act as described in Supplement 8 to Attachment 2.6-A.

TN No: 10-005 Approval Date _‘7 jE hio Effective Date 04/01/10

Supersedes TN No. 91-014

Revision: ATTACHMENT 2.2-A Page 9b State: Maine

Agency Citation(s) Groups Covered

A. Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued)

1902(a)(10)(E)(i), 25. Qualified Medicare Beneficiaries --

1905(p) and

1860D-14(a)(3)(D) a. Who are entitled to hospital insurance benefits under

of the Act Medicare Part A, (but not pursuant to an enrollment under

section 1818A of the Act);

b. Whose income does not exceed 100 percent of the Federal poverty level; and

c. Whose resources do not exceed three times the SSI resource limit, adjusted annually by the increase in the consumer price index.

(Medical assistance for this group is limited to Medicare cost-sharing as defined in item 3.2 of this plan.)

1902(a)(10)(E)(ii), 26. Qualified Disabled and Working Individuals -- 1905(p)(3)(A)(i),

1905(p) and a. Who are entitled to hospital insurance benefits under 1860D-14(a)(3)(D) Medicare Part A under section 1818A of the Act;

of the Act

b. Whose income does not exceed 200 percent of the Federal poverty level; and

c. Whose resources do not exceed two times the SSI resource limit. d. Who are not otherwise eligible for medical assistance under

Title XIX of the Act.

(Medical assistance for this group is limited to Medicare Part A premiums under section 1818A of the Act.)

TN No: 10-005 Approval Date "7 Ee ho Effective Date 04/01/10 Supersedes

TN No. 93-005

Revision: ATTACHMENT 2.2-A Page 9b1

State: Maine

Agency Citation(s) Groups Covered

A. Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued)

1902(a)(10)(E)(iii), 27. Specified Low-Income Medicare Beneficiaries --

1905(p)(3)(A)(ii), and

1860D-14(a)(3)(D) Who are entitled to hospital insurance benefits under

of the Act Medicare Part A (but not pursuant to an enrollment under section 1818A of the Act);

»

b. whose income is greater than 100 percent but less than 120 percent of the Federal poverty level; and

c. Whose resources do not exceed three times the SSI resource limit, adjusted annually by the increase in the consumer price index.

(Medical assistance for this group is limited to Medicare Part B premiums under section 1839 of the Act.)

1902(a)(10)(E)(iv), 28. Qualifying Individuals --

1905(p)(3)(A)(ii) and

1860D-14(a)(3)(D) Who are entitled to hospital insurance benefits under

of the Act Medicare Part A (but not pursuant to an enrollment under section 1818A of the Act);

»

b. whose income is at least 120 percent but less than 135 percent of the Federal poverty level;

c, Whose resources do not exceed three times the SS] resource limit, adjusted annually by the increase in the consumer price index.

TN No: 10-005 Approval Date 1/4 ) Ye) Effective Date 04/01/10 Supersedes

TN No. 93-005

/s/

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203 CfNER5 far MED/CQRE & MfDfCA1D SERWCES Division of Medicaid and Children's Health Operations / Boston Regional Ofice December 2 1.20 10 Brenda M. Harvey, Commissioner Department of Health and Human Services 11 State House Station Augusta, Maine 04333-001 1 Dear Commissioner Harvey: We are now ready to approve State plan amendment (SPA) No. 10-01 1 ; attached you will find an approved copy of the SPA. This SPA is effective September 1,2010 as requested. This SPA transmitted an amendment to your approved Title XIX State plan to assure comparability amount, scope and duration of services made available to categorically and medically needy populations in the State plan. This amendment clarifies that all services provided for medically needy groups are identical in amount, duration, and scope as those for categorically needy groups. We reviewed this SPA for compliance with $1902(a)(73) of the Act as added by $5006(e) of the American Recovery and Reinvestment Act of 2009, Public Law 1 1 1-5. We determined that this SPA would benefit all Medicaid beneficiaries and providers including members of federally recognized tribes and Indian Health Services contract health services providers. We ask that your Department inform the federally recognized tribes in your state of the changes brought forth by the Recovery Act and this SPA. If there are questions, please contact Kathryn Holt at 6 171.565- 1246 or via email at kathryn. holt@cms.hhs.gov. Sincerely, Richard R. McGreal Associate Regional Administrator Enclosure cc: Tony Marple, Director, Office of MaineCare Services

Table of Contents

State/Territory Name: Maine State Plan Amendment (SPA) #: 10-014 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group January 30, 2020 VIA E-Mail Jeanne Lambrew, Commissioner Department of Health and Human Services 221 State Street Augusta, Maine 04333-0011 Dear Commissioner Lambrew: We are pleased to enclose an approved copy of the Maine State Plan Amendment (SPA) 10-014. The SPA was submitted on September 23, 2010. CMS received the State’s formal response to a request for additional information on November 27, 2019. The SPA updates the rehabilitation service language in Attachment 3.1-A of the State plan. The State indicated that there were no changes to coverage, but that more detail was added regarding services and service provider qualifications. The State also indicated that there was no fiscal impact since the SPA reflected current practice. The effective date for this SPA is September 1, 2010, as requested by your agency. If you have questions concerning this letter, please Nancy Grano at 617-565-1695 or at Nancy.Grano@cms.hhs.gov. Sincerely, James G. Scott, Division Director Division of Program Operations /s/

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEAL TH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (CHECK ONE): 1. TRANSMITTAL NUMBER: 2. STATE: 10-014 MAINE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE(S) 9/1/10 0 NEW STATE PLAN O AMENDMENT TO BE CONSIDERED AS NEW PLAN © AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Separate Transmittal for each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Cost Neutral l;LP.AªJ;..NUM.l;lJ;8£>f,Jtl«PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION A Page 1 of Attachment 3.1-A Page 5 and 6, and OR ATTACHMENT (If Applicable): Attachment 3.1-A Pages 5 Page 2 of Attachment 3.1-A Page 5 and 6 ¬)t­'fl(X®;,it through 5(a)(xxv) SUBJECT OF AMENDMENT: BEHAVIORAL HEAL TH SERVICES 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 13. TYPED NAME: BRENDA HARVEY 14. TITLE: Commissioner, Maine Department of Health and Human Services 15. DATE SUBMITTED: 10/24/10 IZI OTHER, AS SPECIFIED COMMISSIONER, DEPT. OF HUMAN SERVICES 16. RETURN TO: ANTHONY MARPLE Director, MaineCare Services #11 State House Station 442 CIVIC CENTER DRIVE Augusta, ME 04333-0011 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 118. DATE APPROVED: PLAN APPROVED-ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE 23. REMARKS 09/23/2010 01/28/2020 09/01/2010 James G. Scott Division of Program Operations Maine and CMS agreed by email on 01/27/2020 and initials to pen and ink changes to correct page numbers in Boxes 8 and 9. /s/

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine Attachment 3.1 A Page 5 AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No. 10-014 APPROVAL DATE: 1-28-20 EFFECTIVE DATE 9-1-10 SUPERSEDES TN No. 04-011 Item 13a. Diagnostic Services

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine Attachment 3.1 A Page 5(a) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ _10-014_ Approval Date: 1-28-20 Effective Date: _9-1-10_ Supersedes TN No.___98-007 1) Assessment: Consists of evaluation, testing, diagnosis, including co-occurring mental health and substance abuse diagnoses, additionally focusing on identification of strengths, developmental and emotional needs, and problems of the members and their families. Services may be performed by a physician (MD/DO), psychiatrist, psychological examiner, psychologist, mental health agency, independently licensed clinician (Licensed Clinical Social Worker (LCSW), Licensed Clinical Professional Counselor (LCPC), Licensed Marriage and Family Therapist (LMFT)), or substance abuse professional (Licensed Alcohol and Drug Counselor (LADC), Certified Alcohol and Drug Counselor (CADC)). These services are prior authorized. These services are for adults and children.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine Attachment 3.1 A Page 5(a)(i) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ _10-014_ Approval Date: 1-28-20 Effective Date: _9-1-10_ Supersedes TN No.___98-007 2) One-time Lead Investigations: Coverage of one-time lead investigations is limited to a health profession’s (lead inspectors) time and activities during an on-site investigation of a child’s primary residence that result from evidence of elevated blood lead levels according to the levels recommended by the Centers for Disease Control and Prevention. Medicaid does not reimburse for testing of secondary dwellings. Medicaid reimbursement is not available for testing of substances (water, paint, etc.), which are sent to a lab for analysis.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine Attachment 3.1 A Page 5(a)(ii) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ _10-014_ Approval Date: 1-28-20 Effective Date: _9-1-10_ Supersedes TN No.___98-007 Item 13b. Screening Services

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine Attachment 3.1 A Page 5(a)(iii) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_ Item 13c. Preventative Services These services are recommended by a physician or other licensed practitioner of the healing arts within the scope of his practice under State law to (a) prevent disease, disability, and other health conditions or their progression; (b) prolong life; and (c) promote physical and mental health and efficiency. 1) Residential Services for Children: Residential services means individually tailored supports that assist with the acquisition, retention, or improvement in skills related to living in the community. These supports are delivered according to different models and may include: a) Assessment; b) Crisis support; c) Behavioral and developmental therapy; d) Medication management; e) Emotional development skills training aimed at promoting behaviors that affect a member’s relations with other people and the member’s attitudes, interest, values, and emotional expression; f) Daily living skills training, aimed at addressing member dysfunction in areas necessary to maintain independent living; g) Interpersonal skills training, such as structured learning therapy, which are aimed at addressing member dysfunction in areas of social appropriateness and social integration; h) Community skill training, such as modeling therapy that is aimed at ameliorating member dysfunction in the awareness and appropriate use of community resources; (1) Services may be performed by a combination of professionals including a psychiatrist, psychologist, MD, APRN (PMHNP or CNS),RN American Academy Certified Nurse (ANCC) Board Certified (RNBC), or RN Certified: AACN (RNC), clinical staff (LCSW, LMSW-CC, LCPC, LCPC-C, LMFT), BHP, OQMHP, and/or Licensed Foster Parent. Residential service providers are licensed by the State of Maine. This service is prior authorized. Services are not provided in Institutions of Mental Disease.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(iv) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

2) Day Habilitation for Children with Cognitive Impairments and Functional Limitation: Provision of regularly scheduled activities, such as assistance with acquisition, retention, or improvement in self-help, socialization and adaptive skills that enhance social development and develop skills in performing activities of daily living and community living. Activities and environments are designed to foster the acquisition of skills, building positive social behavior and interpersonal competence, greater independence and personal choice. Day habilitation services focus on enabling the participant to attain or maintain his or her maximum potential and shall be coordinated with any needed therapies. Services may be provided individually or in a group setting. Services must be provided by a BHP. These services are prior authorized. These services are for children.

a) Specialized Services for Children with Cognitive Impairments and Functional Limitations: Treatment services for children who utilize behavioral interventions designed to improve socially significant behaviors and developmentally appropriate skills to a measurable degree. Services are scientifically-based interventions that have been shown to significantly improve the behavioral achievement of the children. Services may be provided by a Board Certified Behavior Analyst (BCBA) or BHP under the supervision of a psychologist or a BCBA. These services are prior authorized.

b) Children’s Behavioral Health Day Treatment: Services provided in schools in coordination with an Individual Education Plan (IEP) or Individual Family Service Plan (IFSP). Services are structured therapeutic services designed to improve a member’s functioning in daily living and community living. Services include a mixture of individual, group, and activities therapy and also include therapeutic treatment oriented toward developing a child’s emotional and physical capability in the area of interpersonal functioning. Services may include behavioral strategies and interventions. Services may be performed by clinicians (psychiatrist, psychologist, LCSW, LMSW, LCPC, LMFT), MHRT, BCBA, and BHP. Services are delivered in school-based settings. These services are prior authorized.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(v) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_ 13d. Rehabilitative Services –all rehabilitative services are recommended by a physician or other licensed practitioner.

1) Community Integration Services: Provides biopsychological assessment, treatment planning, and care coordination to members in order to restore independent community living. Community Integration workers coordinate referrals and advocates access by the member to service(s) and natural support(s) identified in his or her Individual Support Plan. Services are performed by a Mental Health Rehabilitation Technician – Community (MHRT/C). These services are prior authorized. These services are for adults.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(vi) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

2) Community Rehabilitation Services (CRS): Includes individualized combinations of Community Integration Services, and Behavioral Health Skills Training and Development and must be available 24 hours per day, 7 days a week. Services are performed by a MHRT/C and Mental Health Rehabilitation Technician – Level One (MHRT-I). These services are prior authorized to avoid duplication of services. These services are for adults.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(vii) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

3) Assertive Community Treatment (ACT): Provides individualized intensive integrative services delivered via a multi-disciplinary team of practitioners that are available twenty-four (24) hours a day, seven (7) days a week, 365 days a year. ACT services are recovery based and primarily community- based. They are intended to prevent future admission to psychiatric hospitalization or a residential care facility. Services include assessments, substance abuse treatment, employment-support, treatment planning, illness management and recovery skills, individual supportive therapy, assistance with activities of daily living, medication monitoring, and day-to-day interventions with member and support networks. These services are prior authorized. Services may be performed by the following providers depending on whether the service is for an adult or child:

a) Adult ACT services: Team may include a psychiatrist or Advanced Practice Registered Nurse (APRN) (psychiatric and mental health clinical nurse specialist (CNS), or Advance Practice Psychiatric and Mental Health Registered Nurse Practitioner (PMHNP)), Registered Nurse (RN), certified rehabilitation counselor, employment specialist, Certified Intentional Peer Support Specialist (CIPSS), LADC, CADC, licensed occupational therapist (OT), MHRT/C, psychologist, LCSW or LCPC.

b) Children’s ACT services: Team may include a psychiatrist, APRN (PMHNP or CNS with advanced training in children’s psychiatric mental health and approval of OCFS Medical Director or working under the supervision of a psychiatrist), and LCSW, LCPC, LMFT, psychologist; physician assistant with advanced training in children’s psychiatric mental health; RN with advanced training in children’s psychiatric mental health, LMSW-clinical conditional (LMSW- cc), LCPC conditional (LCPC-c), LADC, CADC, or Other Qualified Mental Health Professional (OQMHP).

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(viii) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

4) Behavioral Health Skills Training and Development Services (1) Includes therapeutic support to restore the adult member’s skills and abilities essential to independent living and avoiding crises intervention or hospitalization. There services reorient members to time, place, and circumstance. Services may be in an individual or group setting and may use various evidence based models. Services may be performed by a MHRT/C, MHRT-I, with a Certified Residential Medication Aide (CRMA) and other qualified mental health professional. These services are prior authorized. These services are for adults.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(ix) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

5) Crisis Services: Consists of immediate crisis-oriented therapeutic intervention services provided to members with a serious problem of disturbed thought, behavior, mood, or social relationships. Services are oriented toward the amelioration and stabilization of these acute emotional disturbances to ensure the safety of a member or society. Services include all components of screening, assessment, planning, evaluation, intervention, and disposition, and are available twenty-four (24) hours a day, seven (7) days a week. Providers are contracted with DHHS. Services must be performed by a certified MHRT. Out-of-home Crisis Residential Services are prior authorized. These services are for adults and children.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(x) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

6) Medication Assisted Treatment (MAT): Consists of treatment for substance use disorder that includes the use of methadone and in accordance with regulations from the Substance Abuse and Mental Health Services Agency. Services include assessment, planning, counseling, drug use disorder testing, and medication administration. Services may be performed by a MD/DO, psychologist, APRN, LADC, CADC, LCSW, LCPC, and LMFT. These services are for adults and children.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xi) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

7) Enhanced Family Treatment: Designed for youth needing a higher intensity of services than outpatient therapy, but lower than Children’s Assertive Community Treatment. Enhanced Family Treatment is a structured, consistent, strength-based therapeutic relationship between a licensed clinician and the youth and family for the purpose of treating the youth’s behavioral health needs, including improving the family’s ability to provide effective support for the youth to promote his/her healthy functioning within the family. Interventions include behavior modification and family therapy. Enhanced Family Treatment may utilize various evidence-based models. This service is prior authorized. Services are provided to members via a team approach or by an individually licensed mental health professional (Psychologist, LCSW, LMSW-CC, LCPC, LCPC-C, LMFT, LMFT-C) and a certified Behavioral Health Professional (BHP). These services are for children. These services are for the direct benefit of the child.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xii) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

8) Therapy and Counseling Services: Therapy and Counseling services are provided in an individual or group setting, focusing on developmental, emotional needs, and problems of members and their families. These services include specific therapies based on evidence-based models. Services may be provided to members with mental health and/or substance abuse disorders. These services are prior authorized and have a limit of seventy-two (72) quarter-hour units of service per year. Additional units may be authorized if medical necessity standards are met. Services may be performed by a psychologist, LCSW, LMSW-CC, LCPC, LCPC-C, LMFT, LADC, CADC, MD/DO, or APRN. Certain evidence-based models may also include a CIPSS, psychiatric nurse, certified rehabilitation counselor, RN under supervision of a psychiatrist, physician assistant under the supervision of a psychiatrist, PMHNP, OT, certified employment specialist, MHRT, or CRMA. These services are for adults and children.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xiii) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

9) Family Psychoeducation Treatment: Evidence-based practice provided via single-family session or multi-family groups. Clinical elements include engagement sessions, psychoeducational workshops, and on-going treatment sessions focused on solving problems that interfere with treatment and rehabilitation, including co-occurring mental health and substance abuse diagnoses. Services are performed by a physician, psychiatrist, psychologist, PA, LCSW, LFMT, LCPC, LMSW, APRN (PMHNP, CNS), or a MHRT. Psychoeducational treatment to the beneficiary’s family is for the direct benefit of the beneficiary, in accordance with the beneficiary’s needs and treatment goals identified in the beneficiary’s treatment plan, and for the purpose of assisting in the beneficiary’s recovery.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xiv) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

10) Intensive Outpatient Services (IOP): Intensive and structured service of alcohol and drug assessment, diagnosis, including co-occurring mental health and substance abuse diagnoses, and treatment services in a non-residential setting aimed at members who meet ASAM placement criteria level II.1 or level II.5. Services may include individual, group, or family counseling as part of a comprehensive treatment plan. Services are delivered for a minimum of three (3) hours per diem, three (3) days a week. Services must be provided under the direction of a physician (MD/DO) or psychologist, and delivered by a qualified staff (APRN, LADC, CADC, LCSW, LMSW-CC, LCPC, LCPC-C, LMFT, LMFT-C). These services are for adults and children.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xv) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

11) Neurorehabilitation/Neurobehavioral Services: Designed to address the unique medical, physical, cognitive, psychological, and behavioral needs of members with acquired brain injuries. Services include clinical assessment services, intensive integrated neurorehabilitation, neurobehavioral rehabilitation, compensatory interventions and treatment,, a. Services are performed both one-on-one and in groups by the following professionals: MD, DO, neuropsychologist, RN, certified therapeutic recreation specialist, OT, certified Occupational Therapist Assistant-Licensed (OTA-L), Physical Therapist (PT), licensed Physical Therapist Assistant (PTA), speech language pathologist, speech language pathology assistant, social worker, Licensed Professional Counselors (LPC), LCPC, or other qualified staff. These services are for adults and children.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xvi) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

12) Clinically Managed Residential Services (includes high-intensity adult criteria and medium- intensity adolescent criteria): Delivered in accordance to ASAM Level 3.5, these services are designed to treat persons who have significant social and psychological problems. Services include therapeutic treatment and planning consisting of assessment, diagnostic, and counseling services. The treatment mode may vary with the member’s needs and may be in the form of individual, group or family counseling. These services are delivered by a physician, psychiatrist, psychologist, LCSW, LCPC, LPC, RN, Licensed Practical Nurse (LPN), LADC, other qualified alcohol and drug treatment staff. These services are for adults and children.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xvii) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

13) Medically Monitored Inpatient Programs (intensive for adults, high-intensity for adolescents): Delivered in accordance to ASAM Level 3.7 which provides a planned a structured regimen of 24- hour professionally directed evaluation, observation, medical monitoring, and addiction treatment in an inpatient setting. Services are intended for individuals who have recent history of lower levels of treatment or have comorbid physical emotional, behavioral, or cognitive conditions, which increases clinical severity and complicate withdrawal management. Services provide immediate diagnosis and care to members having acute physical problems related to substance abuse. Each episode is limited to seven (7) days, but may be extended if medically necessary. Services are provided by physicians, psychiatrists, psychologists, social workers, LPCP, LPC, RN, LPN, LADC, psychiatric nurses, CADC, and other qualified alcohol and drug treatment staff. These services are for adults and children.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xviii) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

14) Clinically Managed Population- Specific High Intensity Residential Programs (specified for adults only): Delivered in accordance with ASAM Level 3.3, this service provides scheduled therapeutic plan consisting of treatment services designed to enable the member to sustain a substance free life style within a supportive environment. The treatment mode may vary with the member’s needs and may be in the form of individual, group or family counseling These services are limited to two hundred seventy (270) covered days on an annual basis per member, unless the member has a documented need to exceed that limit. Services are provided by a physician, psychiatrist, psychologist, social worker, LCPC, LPC, RN, LPN, LADCs, Psychiatric nurse, CADC, and other qualified alcohol and drug treatment staff. These services are for adults.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xix) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

15) Clinically Managed Low-Intensity Residential Services: Delivered in accordance with ASAM Level 3.1, this service provides scheduled therapeutic and rehabilitative treatments consisting of transitional services designed to enable the member to sustain a substance free life style in an unsupervised community situation. Members are taught attitudes, skills, and habits conducive to facilitating their transition back to the community. Treatment services may be in the mode of individual, group, or family counseling. These services are limited to a single admission of one hundred eighty (180) covered days per member per year, unless a member has a documented need to exceed that limit. Services are provided by a physician, psychiatrist, psychologist, social worker, LCPC, LPC, RN, LPN, LADCs, Psychiatric nurse, CADC, and other qualified alcohol and drug treatment staff. These services are for adults.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xx) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

16) Adult Day Health: Services are available for individuals requiring assistance with ADLs. This service provides health monitoring and personal care services in addition to a group program of care, and therapeutic activities. Therapeutic activities include restorative activities designed to maintain or improve the quality of one’s life or delay deterioration of skills. Services must be provided under an individual plan of care based on an assessment by an approved medical eligibility assessment form. Members eligible for Level 1 of care may receive up to sixteen (16) hours per week of covered services under this Section. Members eligible for Level II of care may receive up to twenty-four (24) hours per week of covered services under this Section. Members eligible for Level III of care may receive up to forty (40) hours per week of covered services under this Section. Day health services are provided at facilities licensed by the Department. Direct services are provided by a CNA, RN, LPN, LCSW, OT/PT, or Speech Language Pathologist. This service is prior authorized. This service is for adults.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xxi) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_

17) Medication Management: Services that are directly related to the psychiatric evaluation, prescription, administration, education and/or monitoring of medications intended for the treatment and management of mental health disorders, substance abuse disorders and/or co-occurring disorders. Services are provided by a physician, psychiatrist, PAs, or APRNs.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xxii) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_ Licensed Providers • Advanced Practice Registered Nurse (APRN) o Advance Practice Psychiatric and Mental Health Registered Nurse Practitioner (PMHNP) o Clinical Nurse Specialist (CNS) o Nurse Practitioner (NP) • Doctor of Osteopathy (DO) • Foster Parents: have at least six (6) months experience working with children with disabilities and receive ongoing training in the Treatment Foster Care model and are licensed by the State of Maine. For multidimensional foster care, foster parents must complete a minimum of 12 hours of training on the model of treatment, and they have ongoing support from a treatment parent consultant/recruiter/trainer. • Licensed Alcohol and Drug Counselor (LADC) • Licensed Clinical Professional Counselor (LCPC) • Licensed Clinical Professional Counselor-Conditional (LCPC-C) • Licensed Clinical Social Worker (LCSW) • Licensed Marriage and Family Therapist (LMFT) • Licensed Marriage and Family Therapist-Conditional (LMFT-C) • Licensed Master Social Worker (LMSW) • Licensed Master Social Worker-Conditional Clinical (LMSW-CC) • Licensed Physical Therapy Assistant • Licensed Practical Nurse (LPN) • Licensed Professional Counselor (LPC) • Licensed Psychological Examiner • Licensed Social Worker (LSW) • Medical Doctor (MD) • Mental Health Clinical Nurse Specialist (CNS) • Neuropsychologist • Nurse Practitioner (NP) • Occupational Therapist (OT) • Occupational Therapist Assistant-Licensed • Physical Therapist (PT) • Psychiatrist • Psychiatric nurses: hold a current active RN license and have specialized training and clinical practice in psychiatric-mental health nursing. • Psychological Examiner • Psychologist • Registered Nurse (RN)

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xxiii) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_ • Registered Nurse, ANCC Board Certified (RNBC) • Registered Nurse, Certified: American Academy Certified Nurse (RNC) • Registered Professional Nurse (RN) • Speech Language Pathologist

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page 5(a)(xxiv) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_ Unlicensed Providers • Behavioral Health Professional: complete 50-hour training program to earn BHP certification within one year of hire as a BHP, at least 18 years of age, have high school diploma or equivalent, have Bachelor’s degree in related field, and have certification in CPR, First Aid, and Blood Borne Pathogens • Board Certified Behavior Analyst (BCBA): Master’s or Doctoral level degree from accredited college or university with completion of acceptable graduate coursework in behavior analysis. BCBAs must take and pass a BCBA exam, and must be certified by the Behavior Analyst Certification Board. • Certified Alcohol and Drug Counselor: At least 18 years of age, take and pass board exam, pay application and certification fee, and meet one of the following education requirements: high school diploma or equivalent and minimum of 4,000 hours documented clinically supervised work experience as an alcohol and drug counseling aide consisting of at least 3 of the following functions: clinical evaluation consisting of intake screening and differential assessment, treatment planning including initial, ongoing and discharge planning, counseling of individuals, groups, couples or families, case management, and/or client and family education OR at a minimum, course work as defined by board rule or an associate degree from accredited college or university in behavioral sciences, addiction counseling or a related field as defined by board rule. • Certified Employment Specialist: completed Association of Community Rehabilitation Educators (ACRE) approved course, or other employment specialist training approved by Department of Health and Human Services (DHHS) and maintains certification • Certified Rehabilitation Counselor: national certification from Commission on Rehabilitation Counselor Certification • Certified Intentional Peer Support Specialist: completed DHHS Office of Substance Abuse and Mental Health Services (SAMHS) curriculum for CIPSS and receives and maintains certification • Certified Residential Medication Aide: certification from DHHS as CRMA, which requires 40- hour certified CRMA training program. • Certified Therapeutic Recreation Specialist: completed 4-year program in therapeutic recreation from accredited college or university and be certified as a therapeutic recreation specialist under National Council for Therapeutic Recreation Certification • Employment Specialist: other qualified individual who has completed DHHS approved employment specialist training. • Mental Health Rehabilitation Technician (MHRT/1): Be at least 18 years old, Complete 35-hour Mental Health Support Specialist training program, Complete an approved behavioral intervention program, Complete the 40-hour Certified Residential Medication Aide (CRMA) training program, Complete CPR and first-aid training

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFICIAL STATE: Maine

Attachment 3.1 A Page(a)(xxv) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.__ 10-014 Approval Date: 1-28-20 Effective Date:_ 9-1-10 Supersedes TN No.__ 98-007_ • Mental Health Rehabilitation Technician/Community (MHRT/C): certification from DHHS, which requires the following ten courses be completed: Introduction to Community Mental Health, Psychosocial Rehabilitation, Interviewing and Counseling, Crisis Identification and Resolution, Cultural Competency/Diversity, Vocational Aspects of Disability, Substance Abuse with a Dual Diagnosis Component, Sexual Abuse, Trauma, and Recovery, Case Management, Mental Health and Aging • Other Qualified Alcohol and Drug Treatment Staff: are staff that have appropriate education, training, and experience in substance abuse treatment services, related disciplines as approved by the Office of Substance Abuse (OSA), or behavioral sciences; who work under a substance abuse treatment professional, consisting of at least one (1) hour per week for each twenty (20) hours of covered services rendered; and who are approved by the State Board of Alcohol and Drug Counseling as documented by written evidence on file with that office pursuant to Section 4.19 of the Regulations for Licensing/Certifying Substance Abuse Treatment Facilities in the State of Maine. • Other Qualified Mental Health Professional (OQMHP): Is staff that has education, training, or experience that qualifies them to perform certain specified mental health functions. They receive certification from the Department, or its designee, that they are qualified to perform such functions and such verification is recorded in writing and kept in the files of the Department, or its designee; and they perform such functions under the supervision of a licensed, certified, or registered health professional with the supervisory relationship having been described to and approved by the Department in accordance with its licensing and certification regulations. • Other Qualified Staff: staff with appropriate education, training, and experience in treatment of individuals with brain injury as approved by the Commission on Accreditation of Rehabilitation Facilities (CARF), have a satisfactory criminal background check annually, and work under documented supervision, conducted at least monthly, by the professionals as defined here. • Speech Language Pathology Assistant: must be register under the license of a speech-language pathologist in the state or province in which services are provided; and work only under the supervision of that speech-language pathologist.

Table of Contents

State/Territory Name: Maine State Plan Amendment (SPA) #: 10-016 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group January 30, 2020 VIA E-Mail Jeanne Lambrew, Commissioner Department of Health and Human Services 221 State Street Augusta, Maine 04333-0011 Dear Commissioner Lambrew: We are pleased to enclose an approved copy of the Maine State Plan Amendment (SPA) 10-016. The SPA was submitted on September 23, 2010. CMS received the State’s formal response to a request for additional information on November 27, 2019. The SPA updates the personal care service language in Attachment 3.1-A of the State plan. The State added detail regarding personal care and personal care attendant services and providers of service. The State indicated that there was no fiscal impact from this SPA. The SPA was approved January 28, 2020, with an effective date of September 1, 2010, as requested by your agency. If you have questions concerning this letter, please Nancy Grano at 617-565-1695 or at Nancy.Grano@cms.hhs.gov. Sincerely, James G. Scott, Division Director Division of Program Operations /s/

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEAL TH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (CHECK ONE): 1. TRANSMITTAL NUMBER: 2. STATE: 10-016 MAINE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE(S) 9/1/10 0 NEW STATE PLAN O AMENDMENT TO BE CONSIDERED AS NEW PLAN « AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate Transmittal for each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Cost Neutral . PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ffitAGf'.IMEN'F ro &4-A;-(-AAGE:r¬Al OR ATTACHMENT (It Applicable): Attachment to Attachment to Attachment 3.1-A, Page 10 through Page 1 O(a Wr-A6HMeH:i--0­-A.9;4®aGA Attachment 3.1-A, Pa SUBJECT OF AMENDMENT: PERSONAL CARE SERVICES 10 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 13. TYPED NAME: BRENDA HARVEY 14. TITLE: Commissioner, Maine Department of Health and Human Services 15. DATE SUBMITTED: 10/24/10 « OTHER, AS SPECIFIED COMMISSIONER, DEPT. OF HUMAN SERVICES 16. RETURN TO: ANTHONY MARPLE Director, MaineCare Services #11 State House Station 442 CIVIC CENTER DRIVE Auausta, ME 04333-0011 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 118. DATE APPROVED: PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE 23. REMARKS 9/23/10 1/28/20 9/1/10 James G. Scott Division Director, Division of Program Operations Maine and CMS agreed by email January 27, 2020 and by initials to the pen and ink changes to correct page numbers in Boxes 8 and 9. /s/

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: Maine OFFICIAL Attachment to Attachment 3.1- A Page 10 AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.10-016 Approval Date: 1/28/20 Effective Date: 9/1/10 Supersedes TN No. 02-003 26. Personal Care Services Personal care services provided through the State Plan are provided either by consumer-directed Personal Care Attendants (PCAs), personal care agencies, Adult Family Care Homes (AFCHs), or Private Non- Medical Institutions (PNMIs). A. Personal Care Attendant (PCA) services All personal care services provided by a PCA through the State Plan are consumer directed, and the consumer (the MaineCare member) is the employer of his/her PCAs. PCA services furnished under the State Plan are limited to “employer authority” only. That is, all PCA funds under the PCA State Plan must be used solely to pay for employer required tasks, and cannot be used for any other purpose, such as the purchase of products and services other than those provided by a PCA to meet the consumer’s personal care needs. All consumers are responsible for hiring, firing, training, and scheduling PCAs, as well as submitting activity forms to the Fiscal Intermediary (FI). The State contracts with FIs in accordance with the requirements of 42 CFR 434.10 to perform employer required tasks and administrative tasks on behalf of consumers. The FI receives and processes the PCA timesheet, and submits claims for PCA services through the State’s MMIS system. The State processes the claim and pays the FI to perform all employer required tasks on behalf of the consumer. 1) For the State to pay for consumer-directed personal care services provided by a PCA, the consumer must be able to be appropriately cared for in the home and the following conditions must be met: a) The personal care services must meet the State’s medical necessity criteria and must be authorized by the State or the Assessing Services Agency prior to being provided in accordance with the authorized service plan. b) The personal care services must, in accordance with 42 CFR 440.167, be authorized for an individual in accordance with a service plan approved by the State. 2) If the conditions in 1 are met, the State will pay for a consumer to receive physical assistance with activities of daily living (ADLs) and Instrumental Activities of Daily Living (IADLs) and/or health maintenance activities, which are directly related to the member’s plan of care. These tasks must be performed in conjunction with direct care to the member. IADLs and health maintenance activities are those activities that would otherwise be normally performed by the member if he or she were physically able to do so. 3) The qualifications of personal care attendants are described in Section D.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: Maine

OFFICIAL

Attachment to Attachment 3.1- A Page 10(a) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.10-016 Approval Date: 1/28/20 Effective Date: 9/1/10 Supersedes TN No. 02-003

B. Personal care agency services

1. For the State to pay for personal care services provided by a personal care agency, the consumer must be able to be appropriately cared for in the home and the following conditions must be met:

a) The personal care services must meet the State’s medical necessity criteria and must be authorized by the State or the Assessing Services Agency prior to being provided in accordance with the authorized service plan.

b) The personal care services must, in accordance with 42 CFR 440.167, be authorized for an individual in accordance with a service plan approved by the State.

2. If the conditions in 1 are met, the State will pay for a consumer to receive physical assistance with ADLs and IADLs and/or health maintenance activities, which are directly related to the member’s plan of care. These tasks must be performed in conjunction with direct care to the member. IADLs and health maintenance activities are those activities that would otherwise be normally performed by the member if he or she were physically able to do so.

Family Provider Service Option (FPSO) is an option available to certain eligible members that allows the member to manage his or her own personal care services or to have a family provider agency manage the services. The management includes: hiring, firing, training, maintaining records, and scheduling the personal support specialist(s).

3. Personal care services delivered by personal care agencies may be delivered by personal care attendants, registered nurses, licensed practical nurses, home health aides, certified nursing assistants, Certified Residential Medication Aide (CRMA), or a Personal Support Specialist (PSS). The provider qualifications for these provides is included in Section D.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: Maine

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Attachment to Attachment 3.1- A Page 10(a)(i) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.10-016 Approval Date: 1/28/20 Effective Date: 9/1/10 Supersedes TN No. 02-003

C. Adult Family Care Homes (AFCH)

Personal care services provided by a licensed AFCH are provided in a community-based setting operated by the AFCH and delivered by direct care staff of the AFCH. AFCHs are residential style homes for eight or fewer residents, which are licensed by the Department pursuant to the Regulations Governing the Licensing and Functioning of Assisted Housing Programs. AFCH services are not provided in an Institute for Mental Disease servicing individuals aged 22-64.

A member who is eligible to receive personal care services provided by an AFCH may obtain those services from any qualified AFCH participating in MaineCare. Personal care services are provided by AFCH’s direct care staff in accordance with a written individual service plan that is developed within thirty calendar days of admission based upon the findings of the resident assessment instrument, with the participation of the members (and the member’s surrogate, if applicable), describing in detail the responsibilities of the member and the residential care provider (and the member’s surrogate, if applicable). The plan describes strategies and approaches to meet the resident’s needs, how the AFCH will arrange and deliver services, the frequency of each service that will be provided and how those services will address the goals to improve or maintain the beneficiary’s level of functioning. The service plan shall be modified, as necessary, based upon identified changes.

The Minimum Data Set- Assisted Living Services (MDS-ALS) is the assessment tool approved by the Department to provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. The Department utilizes this tool to divide members into resource groupings that determine the resource-adjusted price for each member.

1. For the State to pay for personal care services provided by an AHCH to a member, the member must be able to be appropriately cared for in the AFCH setting and the following conditions must be met:

a) The personal care services provided to the member by the AFCH’s direct care staff must meet the State’s medical necessity criteria and must be authorized by the State or the Assessing Services Agency prior to being provided in accordance with the authorized service plan.

b) The personal care services must, in accordance with 42 CFR 440.167, be authorized for an individual in accordance with a service plan approved by the State.

2. If the conditions in 1 are met, the State will pay for a consumer to receive physical assistance with ADLs and IADLs and/or health maintenance activities, which are directly related to the member’s plan of care. These tasks must be performed in conjunction with direct care to the member. IADLs and health maintenance activities are those activities that would otherwise be normally performed by the member if he or she were physically able to do so.

3. Personal care services delivered in AFCHs must be delivered by the AFCH’s direct staff.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: Maine

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Attachment to Attachment 3.1- A Page 10(a)(ii) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.10-016 Approval Date: 1/28/20 Effective Date: 9/1/10 Supersedes TN No. 02-003

D. Private Non-Medical Institution Services (PNMI)

Personal care services provided by a PNMI are provided in a community-based setting operated by the PNMI provider and delivered by direct care staff of the PNMI. PNMI services are not provided in an Institute for Mental Disease servicing individuals aged 22-64.

A member who meets medical necessity criteria to receive personal care services provided by a PNMI may obtain those services from a qualified PNMI participating in MaineCare. Personal care services are provided by PNMI’s direct care staff in accordance with a written individual service plan based upon the findings of the appropriate State-approved assessment tool, with the participation of the members (and the member’s surrogate, if applicable), describing in detail the responsibilities of the member and the PNMI (and the member’s surrogate, if applicable). The Plan also describes strategies and approaches to meet the resident’s needs, names of who will arrange and/or deliver services, when and how often services will be provided and goals to improve or maintain the resident’s level of functioning. The service plan shall be modified, as necessary, based upon identified changes.

1. For the State to pay for personal care services provided by a PNMI to a member, the member must be able to be appropriately cared for in the PNMI setting and the following conditions must be met:

a) The personal care services provided to the member by the PNMI’s direct care staff must meet the State’s medical necessity criteria and must be authorized by the State or the Assessing Services Agency prior to being provided in accordance with the authorized service plan. b) The personal care services must, in accordance with 42 CFR 440.167, be authorized for an individual in accordance with a service plan approved by the State.

2. If the conditions in 1 are met, the State will pay for a consumer to receive physical assistance with ADLs and IADLs and/or health maintenance activities, which are directly related to the member’s plan of care. These tasks must be performed in conjunction with direct care to the member. IADLs and health maintenance activities are those activities that would otherwise be normally performed by the member if he or she were physically able to do so.

3. Personal care services delivered in PNMIs must be delivered by the facility’s direct staff.

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: Maine

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Attachment to Attachment 3.1- A Page 10(a)(iii) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.10-016 Approval Date: 1/28/20 Effective Date: 9/1/10 Supersedes TN No. 02-003

D. Provider Qualifications

1. Licensed Providers a. Registered Professional Nurse b. Licensed Practical Nurse c. Adult Family Care Homes d. Private Non-Medical Institutions

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: Maine

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Supplement 1 to Attachment 3.1-A Page 10(a)(iv) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.10-016 Approval Date: 1/28/20 Effective Date: 9/1/10 Supersedes TN No. 02-003

2. Unlicensed Providers a. Certified Nursing Assistant (CNA) who meets the following criteria: i. Meets all applicable State laws and regulations as are currently in effect; ii. Is employed by, or acting under a contractual relationship with, a licensed home health agency; iii. Has satisfactorily completed training for certified nurse assistants consistent with, and receive supervision consistent with, the Rules and Regulations of the Maine State Board of Nursing; and, iv. Is listed on the CNA registry. b. Certified Nursing Assistant/Medications who meets the following criteria: i. Is a CNA as described above who has also satisfactorily completed a Department-approved medication course for Certified Nursing Assistants, consistent with the Rules and Regulations of the Maine State Board of Nursing. c. Certified Residential Medication Aide (CRMA) who meets the following criteria: i. Is employed by a licensed assisted living agency that holds a valid contract with the Maine Office of Aging and Disability (OADS) and provides medication administration as allowable under certification. d. Personal Care Attendants must meet the following criteria: i. Must be at least seventeen years old; ii. Cannot be the consumer’s family member; iii. Must be legally authorized to work in the United States; iv. Must be able to understand and carry out direction given by the consumer of the consumer’s surrogate; v. Must be willing to receive training and supervision in all PCA tasks from the consumer or the consumer’s surrogate. vi. Within twenty-one (21) days of initiating services, the PCA must be deemed competent through a Statement of competency from the member. vii. Cannot be an individual who has a notation on the Maine Registry of Certified Nursing Assistants of (a) any criminal convictions, except for Class D and Class E convictions over ten (10) years old that did not involve as a victim of the act, a patient, client, or resident of a health care entity; or (b) any specific documented findings by the State Survey Agency of abuse, neglect or misappropriation of property of a resident, client or patient e. Personal Support Specialist (PSS) i. A PSS must be employed by, or acting under a contractual relationship with a licensed home health agency, registered personal care agency, or licensed assisted living agency, under contract with OADS. The following requirements must be met: 1. Criminal background check and CNA registry check. 2. A PSS must meet one of the following: a. Hold a valid certificate of training for nursing assistants or have official documentation of equivalent training as verified by the Office of the Maine CNA Registry, and be currently listed on the Maine CNA Registry without any annotation that would prohibit that individual from employment; or

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: Maine

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Supplement 1 to Attachment 3.1-A Page 10(a)(v) AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY TN No.10-016 Approval Date: 1/28/20 Effective Date: 9/1/10 Supersedes TN No. 02-003

b. Hold a valid certificate of training, which meets the standards of the Maine State Board of Nursing- nursing assistant training program; or c. Hold a valid certificate of training as a personal care assistant/PSS; or d. Be a PSS who successfully completed a Department-approved curriculum prior to September 1, 2003. Such individuals will be grand fathered as a qualified personal care assistant/PSS; or e. Obtain a waiver from the Department, the Assessing Services Agency, or the Service Coordination Agency. This is only for PSSs under the FPSO if the PSS has provided services to the Member prior to July 1, 2004. Otherwise, the PSSs must meet the training and competency requirements described above. f. A PSS, newly hired by an agency, who meets the Department’s PSS training requirements, must receive an agency orientation. g. With the exception of FPSO, a newly hired PSS who does not yet meet the Department’s training and examination requirements must undergo an orientation that reviews the role, responsibilities and tasks of the PSS. The PSS must demonstrate competency to the employing agency in all required tasks prior to being assigned to a member’s home, with the exception of health maintenance activities, where by a PSS can demonstrate competency via on the job training once being assigned to a member’s home. h. A family provider agency must provide adequate orientation for the PSS to meet the needs of the member(s). Adequacy shall be determined by the Service Coordination Agency. i. A family member who meets the requirements of this Section may be a PSS and receive reimbursement for delivering personal care services, with the exception of the MaineCare member’s spouse, or the parent (including stepparent) of a minor child who is a MaineCare member in accordance with 42 CFR 440.167. j. An individual without the required training may be hired and reimbursed for delivering personal care services as long as the individual enrolls in a certified training program within sixty days of hire and completes training and examination requirements within nine months of employment and meets all other requirements. If the individual fails to pass the examination within nine months, reimbursement for his or her services must stop until such time as the training and examination requirements are met.

Table of Contents State/Territory Name: Maine State Plan Amendment (SPA) #: 11-009 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203 CA#S CENTERS for MEDICARE & MEDICAID SEHVICES Division of Medicaid and Children's Health Operations I Boston Regional Office Mary C. Mayhew, Commissioner Department of Health and Human Services Commissioner's Office 11 State House Station August, Maine 04333-0011 Dear Commissioner Mayhew: January 12, 2012 We are pleased to enclose a copy of approved State plan amendment (SPA) No. 11-009 with an effective date of October 1, 2011 as requested by your Agency. This SPA transmitted a proposed amendment to Maine's approved Title XIX State plan to amend its State Plan so that the State can be in compliance with the mandatory provision in Section 2302 ofthe Patient Protection and Affordable Care Act (PPACA), entitled Hospice Care for Children. Section 2302 requires that children are able to receive hospice and curative care concurrently. There is no fiscal impact as these federally required services are already being provided. We reviewed this SPA for compliance with § 1902( a)(73) of the Social Security Act, as added by §5006(e) ofthe American Recovery and Reinvestment Act of2009, Public Law 111-5. This SPA was also reviewed in conjunction with provisions ofthe Affordable Care Act, Public Law 111-148. Ifthere are questions, please contact Robert Cruz. He can be reached at (617) 565-1257. Sincerely, rkbJ~111~ Richard R. McGreal Associate Regional Administrator Enclosure cc: Stefanie Nadeau, Director, Office ofMaine Care Services /s/

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (CHECK ONE): 1. TRANSMITIAL NUMBER: 2. STATE: 11-009 MAINE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE(S) October I, 20 II 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN ~ AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate Transmittal for each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: SECTION 1902(A)(80), SOCIAL SECURITY ACT, P.L. 111-148 a. FFY 11 $ 0 ACA SECTION 2302 b. FFY 12 $ 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Attachment 3.1-A, Page 7 Attachment 3.1-A, Page 7 SUBJECT OF AMENDMENT: HOSPICE FOR CHILDREN 11. GOVERNOR'S REVIEW (Check One): 13. 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL TITLE: Commissioner, Maine Department of Health and Human Services k8] OTHER, AS SPECIFIED COMMISSIONER, DEPT. OF HUMAN SERVICES 16. RETURN TO: PATRICIA DUSHUTTLE Director, Policy Division, Office of MaineCare Services #11 State House Station 15. DATE SUBMITTED: October 14,2011 442 CIVIC CENTER DRIVE ME 04333-0011 pen ink changes: Updated Box 4 !Tom 1/04/11 to 10/1/11 which is the earliest effective date for this SPA. The State has confirmed that they have adhered to Affordable Care Act changes described in this SPA since January 4, 2011 . Updated Box 8 and 9 to add "Attachment 3.1-A" so the entire Box reads "Attachment 3.1-A, Page 7." . Updated Box 15 to reflect the actual date this SPA was submitted. Change the effective date on the plan page to October I, 20 II. /s/

10/1/11 1/12/12 11-009 01-004

Table of Contents: State Plan Amendment ME 12-015 1. Approval Letter 2. CMS Form 179 3. State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

JFK Federal Building. Government Center

Room 2275

Boston, Massachusetts 02203 CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

August 29, 2013

Mary Mayhew, Commissioner Department of Health and Human Services 11 State House Station

Augusta, Maine 04333-0011

RE: Maine 12-015 Dear Commissioner Mayhew:

We are now ready to approve State Plan Amendment (SPA) No. 12-015. Attached you will find an approved copy of the SPA. As requested, this SPA is effective January 1, 2014.

The purpose of this SPA is to amend the cost-sharing sections of the State’s approved Title XIX State Plan to permit Retail and Specialty Pharmacy Services providers to require, as a condition for providing care, items, or services, the payment of any cost-sharing. This SPA also describes the process that the State will use to notify members and providers when out-of-pocket expenses have reached a five percent (5%) aggregate cap and are no longer subject to further premium and costs-sharing for the remainder of the family’s monthly cap period.

If you have any questions regarding this SPA, please contact Kathryn Holt, Maine State Lead, at 617/565-1246, or at kathryn.holt@cms.hhs.gov.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

ce: Stefanie Nadeau, Director, Office of Maine Care Services

TRANSMITTAL AND NOTICE OF APPROVAL OF

STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

1. TRANSMITTAL NUMBER: 2. STATE:

12-015 MAINE 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

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

4. PROPOSED EFFECTIVE DATE(S)

4

5. TYPE OF PLAN MATERIAL (CHECK ONE):

[J NEW STATE PLAN [1] AMENDMENT TO BE CONSIDERED AS NEW PLAN X] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 447.64, 447.68, 447.76, 447.82

7. FEDERAL BUDGET IMPACT: None

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

ATTACHMENT 4.18-F PAGES 1-4 AND PAGES 7-8, ATTACHMENT 4.18-A PAGE 2

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): ATTACHMENT 4.18-F PAGES 1-3 AND 7, ATTACHMENT 4.18-A PAGE 2

SUBJECT OF AMENDMENT: Cost SHARING-PHARMACY SERVICES

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

[_] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

IX] OTHER, AS SPECIFIED COMMISSIONER, DEPT. OF HUMAN SERVICES

12. SIGNATURE OF STATE AGENCY OFFICIAL:

13. TYPED NAME: MARY ©. MAYHEW

16. RETURN TO:

STEFANIE NADEAU

14. TITLE: Director, MaineCare Services Commissioner, Maine Department of Health and Human #11 State House Station Services “45. DATE SUBMITTED: 12/07/12 242 STATE STREET = Augusta, ME_04333-0011

OFFICIAL

Revision: HCFA-PM-85-14 (BERC) ATTACHMENT 4.18-A SEPTEMBER 1985 Page 2 OMB No. 0938-0193

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: Maine

B. | The method used to collect cost sharing charges for categorically needy individuals:

xX Providers are responsible for collecting the cost sharing charges from individuals.

The agency reimburses providers the full Medicaid rate for a service and collects the cost sharing charges from individuals.

Cc. The Basis for determining whether an individual is unable to pay the charge, and the means by which such an individual is identified to providers, is described below:

Pharmacy:

No pharmacy may discount the copayment for promotional purposes. The pharmacy may forgive the copayment for compassionate reasons on an individual basis, but the copayment will still be deducted from the Department's payment to the pharmacy.

TN No. 12-015

Approval Date: August 29, 2013 Effective Date: 01/01/2014 Supersedes

TN No. 92-007

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Attachment 4.18-F Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Maine

It should be noted that States can select one or more options in imposing cost sharing (including co- payments, co-insurance, and deductibles) and premiums.

A. For groups of individuals with family income above 100 percent but below 150 percent of the

FPL: 1. Cost sharing a. __/No cost sharing is imposed b. _X__/Cost sharing is imposed under section 1916A of the Act as follows (specify the amounts by group and services (see below)): Type of Charge

Group if Item/Service Deductible Co-insurance Co-payment *Method of

Individuals Determining Family Income (including monthly or quarterly period)

Non-pregnant Retail and None None $3.00 per Family income is

adults ages 21 Pharmacy prescription, not determined

and over, with Services only. to exceed $30 through the

income over per month DHHS eligibility

100% of the office. The same

federal poverty methodology

level (including that is used to

parent/caretaker determine

relatives. eligibility.

*The Aged, Blind

and Disabled

population is not

included as

Maine only

covers this

population up to

100% of FPL.

TN No. 12-015 Approval Date: 08/29/2013

Supersedes TN No. 09-006 Effective Date 01/01/14

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Attachment 4.18-F Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: Maine

*Describe the methodology used to determine family income if it differs from your methodology for determining eligibility.

Attach a schedule of the cost sharing amounts for specific items and services and the various eligibility

groups.

b. Limitations:

The total aggregate amount of cost sharing and premium imposed under section 1916A for all individuals in the family may not exceed 5 percent of the family income of the family involved, as applied on a monthly and quarterly basis as specified by the State above.

Cost sharing with respect to any item or service may not exceed 10 percent of the cost of such item or service.

c. No cost sharing will be imposed for the following services:

Services furnished to individuals under 18 years of age that are required to be provided Medicaid under section 1902(a)(10)(A)(i), and including services furnished to individuals with respect to whom aid and assistance is made available under part B of title IV to children in foster care and individuals with respect to whom adoption or foster care assistance is made available under part E of such title, without regard to age;

Preventive services (such as well baby and well child care and immunizations) provided to children under 18 years of age, regardless of family income;

Services furnished to pregnant women if such services relate to the pregnancy or to any other medical condition which may complicate the pregnancy;

Services furnished to a terminally ill individual who is receiving hospice care, (as defined in section 1905(o) of the Act);

Services furnished to any individual who is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual’s income required for personal needs;

Emergency services as defined by the Secretary for purposes of section 1916(a)(2)(D) of the Act; Family planning services and supplies described in section 1905(a)(4)(C) of the Act; and

Services furnished to women who are receiving Medicaid by virtue of the application of sections 1902(a)(10)(A)(ii)(XVIJI) and 1902(aa) of the Act.

TN No. 12-015 Approval Date: 08/29/2013 Supersedes TN No. 09-006 Effective Date 01/01/14

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Attachment 4.18-F Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: Maine

d. Enforcement

1._X_/Providers are permitted to require, as a condition for the provision of care, items, or services, the payment of any cost sharing.

2. _X_/(If above box selected) Providers permitted to reduce or waive cost sharing on a case-by-case basis.

3. State payments to providers must be reduced by the amount of the beneficiary cost sharing obligations, regardless of whether the provider successfully collects the cost sharing.

4. States have the ability to increase total State plan rates to providers to maintain the

same level of State payments when cost sharing is introduced.

2. Premiums

No premiums may be imposed for individuals with family income above 100 percent but below 150 percent of the FPL.

B. For groups of individuals with family income above 150 percent of the FFL: 1. Cost sharing amounts

a. __/No cost sharing is imposed. b. _X_/Cost sharing is imposed under section 1916A of the Act as follows (specify amounts by groups and services (see below)):

TN No. 12-015 Approval Date: 08/29/2013 Supersedes TN No. 09-006 Effective Date 01/01/14

OFFICIAL

Attachment 4.18-F

Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Maine Type of Charge Group if Item/Service Deductible Co-insurance Co-payment *Method of Individuals Determining Family Income (including monthly or quarterly period) Non-pregnant Retail and None None $3.00 per Family income adults ages21 Pharmacy prescription, is determined and over, with Services only. nottoexceed _— through the incomes over $30 per month DHHS eligibility 100% of the office. The federal poverty same level. methodology that is used to determine eligibility.

*Describe the methodology used to determine family income if it differs from your methodology for determining eligibility.

TN No. 12-015 Approval Date: 08/29/2013 Supersedes TN No. 09-006 Effective Date 01/01/14

OFFICIAL

Attachment 4.18-F Page 7

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Maine D. Method for tracking cost sharing amounts

Describe the State process used for tracking cost sharing and informing beneficiaries and providers of their beneficiary’s liability and informing providers when an individual has reached his/her maximum so further costs are no longer charged.

The State will track nominal cost sharing for other services through the MMIS.

The proposed premiums range from .32 to 5% of gross income. The Department will consider all premiums/cost sharing considered to be paid by the beneficiary in the calculation of whether an individual beneficiary has incurred family out-of-pocket expenses up to the five percent (5%) cap. Premium/cost sharing data will be tracked for each beneficiary and provided monthly to the Department staff to ensure that family out-of-pocket expenses does not exceed the 5% cap.

Also describe the State process for informing beneficiaries and providers of the allowable cost sharing amounts.

¢ The State will track beneficiaries’ total family out-of-pocket expenses. The State’s tracking process does not rely on beneficiaries.

¢ The State will notify providers when beneficiaries are exempt from cost sharing (i.e. family out-of- pocket expenses have reached the monthly 5% cap, etc.). The State will notify providers by providing an indicator in the point-of-sale system, which will identify exempted members.

¢ = The identification of which month the cap applies to is based on the date of service. The calculation of family out-of-pocket expenses relative to the five percent (5%) cap is completed at the time the is claim adjudicated. The notification to providers, in the Pharmacy point of sale system, is based upon the date the claim is adjudicated. Pharmacy claims are processed immediately through the point of sale system; there are a very small number of pharmacy providers who do not process claims immediately.

TN No. 12-015 Approval Date Effective Date Supersedes TN No. __09-006 08/29/13 01/01/14

OFFICIAL

Attachment 4.18-F Page 8

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State/Territory: Maine

The 5% aggregate cap is calculated on a monthly basis. Members have an established mechanism to dispute charges, should they disagree with the Department’s determination that they have or have not met their monthly aggregate cap or that the Department has not properly identified their exempt status. The appeals process is detailed in Chapter I-General Administrative Policies and Procedures of the MaineCare Benefits Manual which can be found at: https://www.maine.gov/sos/cec/rules/10/ch101.htm.

i. Katie Beckett The processes and requirements regarding the method for tracking cost sharing shall apply to the Katie Beckett population. In addition to the processes and requirements described above, the Department will also adhere to the additional requirements listed below for individuals receiving the Katie Beckett benefit:

© The State will conduct a public meeting on the premiums. The State will issue a letter providing the premium amount to all beneficiaries (members) receiving MaineCare under Certain Disabled Children At Home (Katie Beckett Benefit/TEFRA 134) before implementing the premium requirement.

© The State will also issue a letter to each Katie Beckett member providing the premium amount, method of payment and consequences of non-payment. This information will also be included in the State’s rule and discussed at the public meeting.

E. Indian/Alaskan Native Exemptions

All American Indians/Alaskan Natives (AI/AN) currently receiving or has ever been furnished a service by an I/T/U or through referral under CHS are exempt from all cost sharing.

The State determines when an AI/AN is exempt from cost sharing requirements through two separate and distinct mechanisms, as detailed below.

1.) The State will perform a claims review to determine who has received ITU services

and put an exemption flag in the system; and

2.) A letter provided by the I/T/U to affected beneficiary that identifies them as an individual who is “currently receiving or has ever been furnished a service by an I/T/U or through referral under CHS” and is exempt from all cost sharing. This letter can be presented to the provider by the affected beneficiary. If presented this letter, the provider must exempt the beneficiary from all cost sharing requirements.

TN No. 12-015 Approval Date Effective Date Supersedes TN No. ___ 09-006 08/29/13 01/01/14

Table of Contents State/Territory Name: Maine State Plan Amendment (SPA) #: 13-0028-MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENI'OF HDALTH & HIIMAN SERVICIS Centers for Medicare & Medicaid Scrriccs JFK Federal Building. Covcrnmcnt Centcr Room 2275 Boston. Massachusetts 02203 Division of Medicaid and Children's Health Operations / Boston Regional Office December I 3. 201 3 Mary Mayhew, Commissioner Department of Health and Human Services 1 I State House Station Augusta, Maine 04333-001 I R-E: Maine l3-0028-MM5 Dear Commissioner Mayherv: Enclosed is an approved copy of Maine's State Plan Amendment (SPA) l3-0028-MM5, which was submitted to CMS on September 16.2013. SPA l3-0028-MM5, approved on December 13,2013, updates residency language in the State Plan and affirms that the state meets the requirements of 42 CFR $435.403 and provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. The effective date ofthis SPA is January I , 2014. Enclosed is a copy of the new State Plan page to be incorporated within a separate section at the back of Maine's approved State Plan: . S88. pages I - 4 In addition. enclosed is a summary of State Plan pages which are superseded by ME l3-0028-MM5; this document should be incorporated into a separation section in the front ofthe State Plan. lfyou have any questions regarding this SPA. please contact Kathryn Holt. Maine State Lead. at 6171565- 1246, ot at kathryn.holt@cms.hhs.gov. Sincerely. lsl Richard R. McGreal Associate Regional Administrator cc: Stefanie Nadeau, Director. Office of Maine Care Services crvrs ctNTtts }oR Mtot(ait & J\trDrcArD stRVrcfs March 20, 2014

State/Territory name: Maine Submitted By: Reinhold Bansmer Last Revision Date: Dec 12, 2013 Submit Date: Sep 16, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. ME-13-0028 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.403 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment To ensure compliance with the Affordable Care Act Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Commissioner, Maine Department of Health and Human Services Signature of State Agency Official Page 1 of 2 ME.0329.R00.00 - Jan 01, 2014 03/13/2014 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

DATE RECEIVED:

DATE APPROVED:

PLAN APPROVED – ONE COPY ATTACHED EFFECTIVE DATE OF APPROVED MATERIAL:

SIGNATURE OF REGIONAL OFFICIAL: TYPED NAME Richard R. McGreal TITLE Associate Regional Administrator, Division of Medicaid and Children's Health Operations, Boston Regional Office 9/16/13 12/13/13 1/1/14 /s/

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

ME-13-0028 MM5 STATE:

Maine

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S88 Non-Financial Eligibility- State Residency Attachment 2.6-A, Page 3 PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

(New) Attachment 2.6-A, Page 3, TN 13-0029 MM6

Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility State Residency S88 42 CFR 435.403 State Residency The state provides Medicaid to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions. ✔ Individuals are considered to be residents of the state under the following conditions: Non-institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and: ■ Intends to reside in the state, including without a fixed address, or ■ Entered the state with a job commitment or seeking employment, whether or not currently employed. ■ Individuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in which they live. ■ Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children: ■ Residing in the state, with or without a fixed address, or ■ The state of residency of the parent or caretaker, in accordance with 42 CFR 435.403(h)(1), with whom the individual resides. ■ Individuals living in institutions, as defined in 42 CFR 435.1010, including foster care homes, who became incapable of indicating intent before age 21 and individuals under age 21 who are not emancipated or married: ■ Regardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual's behalf resides in the state, or ■ Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's placement, or ■ If the individual applying for Medicaid on the individual's behalf resides in the state and the parental rights of the institutionalized individual's parent(s) were terminated and no guardian has been appointed and the individual is institutionalized in the state. ■ Individuals living in institutions who became incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement. ■ Individuals who have been placed in an out-of-state institution, including foster care homes, by an agency of the state. ■ Any other institutionalized individual age 21 or over when living in the state with the intent to reside there, and not placed in the institution by another state. ■ IV-E eligible children living in the state, or ■ TN No. 13-0028-MM5 Maine Approval Date: 12/13/13 S88-1 Effective Date: 1/1/14

Page 2 of 4 Medicaid Eligibility Otherwise meet the requirements of 42 CFR 435.403. ■ TN No. 13-0028-MM5 Maine Approval Date: 12/13/13 S88-2 Effective Date: 1/1/14

Page 3 of 4 Medicaid Eligibility Meet the criteria specified in an interstate agreement. Yes No The state has interstate agreements with the following selected states: ■ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply): ■ Are IV-E eligible Are in the state only for the purpose of attending school Are out of the state only for the purpose of attending school Retain addresses in both states Other type of individual Name of Type Description + Non-IV-E Adopted children Maine applies the same criteria and procedures of the ICAMA Interstate Agreement to children who are not IV-E eligible. x The state has a policy related to individuals in the state only to attend school. Yes No TN No. 13-0028-MM5 Maine Approval Date: 12/13/13 S88-3 Effective Date: 1/1/14

Page 4 of 4 Medicaid Eligibility Provide a description of the policy: An individual under age 21 who is a full-time student in the State of Maine will not be considered a resident of Maine if all of the following conditions exist: - neither of the individual's parents reside in the State of Maine; - the individual is claimed as a tax dependent by someone who resides in a state other than Maine; and - the individual is applying for coverage on his or her own behalf. Otherwise meet the criteria of resident, but who may be temporarily absent from the state. ■ The state has a definition of temporary absence, including treatment of individuals who attend school in another state. Yes No Provide a description of the definition: An individual can be temporarily or voluntarily absent from the State of Maine provided the individual intends to return once the purpose of the absence has been accomplished, unless another state has determined the individual is a resident there. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN No. 13-0028-MM5 Maine Approval Date: 12/13/13 S88-4 Effective Date: 1/1/14

Table of Contents: State Plan Amendment ME 13-025MM2 1. Approval Letter 2. Companion Letter 3. Form 179 4. State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center

Room 2275 Cc eye (xp

Boston, Massachusetts 02203 CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

December10, 2013

Mary C. Mayhew, Commissioner Department of Health and Human Services 221 State House

11 State House Station

Augusta, Maine 04333-0011

Dear Ms. Mayhew:

Enclosed is an approved copy of Maine’s state plan amendment (SPA) 13-0025-MM2, which was submitted to CMS on September 13, 2013. SPA 13-0025-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Maine’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA 13-0025-MM2 includes full approval of your state’s alternative single streamlined paper application and the paper applications used to apply for multiple human service programs. The state is using an interim alternative single streamlined online application and by April 30, 2014 will implement a revised alternative single streamlined online application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following $94 state plan pages and attachments to be incorporated within a separate section at the end of Maine’s approved state plan:

e $94, pages S94-1, $94-2, and $94-3

e Attachment 1 — State of Maine, Department of Health and Human Services Application for MaineCare and Food Supplement Benefits, Form # OFI IMS01(R1-14)

e Attachment 2 — State of Maine Department of Health and Human Services Application for Health Insurance, MaineCare for Families with Children and Pregnant Women, Form #BF1- Cco0l (1/14)

e Attachment 3 — Maine Department of Health and Human Services Application for Food Supplement, TANF, PaS, or MaineCare, Form #OFI APPO1 (R1/14)

e Attachment 4 — Statement of use with respect to the alternative single streamlined online application

In addition, enclosed is a summary of the state plan pages which are superseded by SPA 13-0025-MM2, which should also be incorporated into a separate section in the front of the state plan.

e Superseding pages of state plan material, SPA 13-0025-MM2

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. Please contact Kathryn Holt, kathryn.holt@cms.hhs.gov, or at 617/565-1246, if you have any questions.

Sincerely,

ichard KR. McGrea

Associate Regional Administrator

cc: Stefanie Nadeau, MaineCare Director

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

JFK Federal Building, Government Center Cc M yy

Room 2275 CENTERS FOR MEDICARE & MEDICAID SERVICES

Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

December 10, 2013

Mary C. Mayhew, Commissioner Department of Health and Human Services 221 State House

11 State House Station

Augusta, Maine 04333-0011

Dear Ms. Mayhew,

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA13-0025-MM2), which was submitted to CMS on September 13, 2013. Our review of this submission included a review of the state’s paper and online alternative single streamlined applications and the applications used to apply for multiple human service programs.

The approval of SPA 13-0025-MM2 includes full approval of your state’s alternative single streamlined paper application and the paper applications used to apply for multiple human service programs. Until April 30, 2013, the state is using an interim alternative single streamlined online application. This interim application needs to be revised to reflect the following changes.

Necessary changes: Date by which changes ry Bes: will be completed: The online application will include an opportunity for the April 30, 2014

application filer to indicate which household members are seeking benefits, and which are not. The following questions will not appear for household members not seeking any benefits: e Residency questions (other than information needed to determine whether household members live together) e Allcitizenship and immigration questions Non-MAGI screening questions related to blindness, disability, and Medicare

The following questions will not appear on applications for health | April 30, 2014 coverage only: ¢ Questions regarding Food Supplement benefits, drug or

alcohol treatment, felonies, probation or parole, approved activity and fraudulent misrepresentation

such as worker’s compensation and child support income e Questions regarding all types of assets

¢ Questions regarding income not countable under MAGI, I

In accordance with Maine’s verification plan, income April 30, 2014 | documentation will not be requested from application filers unless the income attestation is not reasonably compatible with electronic | data, or there is no electronic data available for the income type. t -_ | Only applicants who do not appear eligible for Medicaid and CHIP | April 30, 2014

based on income attestation will be asked information about access | to employer-sponsored coverage, beyond what is needed for | Medicaid and CHIP.

l

Please submit the revised alternative single streamlined online application to CMS for review no later than April 1, 2014 to ensure approval by April 30, 2014. We continue to be available to provide technical assistance. If you have any questions about your applications, please contact Dena Greenblum at Dena.Greenblum@cms.hhs.gov or (410) 786-8684. If you have any additional questions about this letter, please contact Kathryn Holt, kathryn.holt@cms.hhs.gov, or at (617) 565-1246

Sincerely,

Richard KR. Mc Associate Regional Administrator

ce: Stefanie Nadeau, MaineCare Director

Tea

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Transmittal Number:

Maine

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-13-0025

Proposed Effective Date 10/01/2013

(mn/dd/yyyy)

Federal Statute/Regulation Citation 42 CFR 435, Subpart J and Subpart M

Federal Budget Impact Federal Fiscal Year

2014

2015

First Year $0.00

Second Year $0.00

Subject of Amendment

Amount

SPA changes to ensure compliance with the Affordable Care Act.

Governor's Office Review

Governor's office reported no comment Comments of Governor's office received Describe:

‘® Other, as specified Describe: Commissioner, Department of Human Services

Signature of State Agency Official Submitted By: Reinhold Bansmer Dec 5, 2013

Sep 13, 2013

Last Revision Date:

Submit Date:

TN # 13-0025MM CMS FORM 179

Page 1 of 2

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: STATE: 13-0025MM2 Maine PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): Section $94 - Eligibility Process Section 2, Page 10, section 2.1(a), TN # 91-14 Section 2, Page 11a, section 2.1(d), TN# 91-13

Transmittal Number: ME-13-0025MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

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

42 CFR 435, Subpart J and Subpart M

Eligibility Process

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

Application Processing

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

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

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

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

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

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

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

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

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

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

The agency also accepts applications by other electronic means:

@ Yes C No

Transmittal Number: ME-13-0025-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

Page 1 of 3

Medicaid Eligibility

Indicate the other electronic means below:

Name of Method Description On-Line Xx Fax Xx Telephone x

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

Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19

Redetermination Processing

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

( Once every 12 months

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

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

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

I] Once every 12 months

(0 Once every 6 months

oO Other, more often than once every 12 months Coordination of Eligibility and Enrollment

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

PRA Disclosure Statement

Transmittal Number: ME-13-0025-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013 Page 2 of 3

Medicaid 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 40 hours per response, including the time to review instructions, search existing data

resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

Transmittal Number: ME-13-0025-MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

Page 3 of 3

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application Online Application

TRANSMITTAL NUMBER: STATE:

ME-13-0025MM2 Maine

Through April 30, 2014, the state is using an interim alternative single streamlined application. After April 30, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

Transmittal Number: ME-13-0025MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

State of Maine Department of Health and Human Services

Application for Health Insurance Return fos ’ MaineCare for Families with Children and Pregnant Women 1. Person Filling Out The Application Name (first, middle initial, last) | Social Security Number | Birthdate (month/day/ (Optional if You Are Not : oe Sex atk Requesting Coverage) Cc fl on ee? | Check one (] married [1] widowed [single [J divorced (1) separated RECD _ 45" DAY Maiden Name 2. Mailing Address

Street, PO Box or RR (include apartment number, in care of , etc.)

sal City: State: Zip code: Home phone Work phone: | If different from your mailing address, write in the address where you actually live: 3. Household Members (List the people who live with you) Last name First name Middle | Sex | Date of | Requesting Social Security | Relationship a initial birth | Coverage? Number to you | (Optional if Not | | Requesting i Coverage) __ —{

4. Household Earning (You are not requ at a later date to provide paystubs or photocopies of paystubs for the last 4 weeks

ired to submit proof of your earnings at this time, but you may be asked

if electronic verification is not

possible) Employer’s Amount How often Hours worked | Name name and phone you earn you are paid each week | —+

|

5. Self-Employment (Attach a copy of your most recent tax return including all schedules)

Name of the person who is self-employed

If you did not file a tax return. Check hereL]

Name of business

Hours worked weekly

4

Transmittal Number: ME-13-0025MM2

Approval Date: December 10, 2013

Effective Date: October 1, 2013

6. Unear equi is til earned Income (You are not required at this time to submit proof of your unearned income, but you may be

asked to at a later date if electronic verification is not possible.)

Note: You don't need to tell us about child support, veteran's payments, or Supplemental Security Income (SSI). ne * _— Where is income from? | How often received? Amount 7 ving income (Social Security, Unemployment, ete.) | (monthly, weekly, ete.) Before deductions

7. Health Insurance

List children in your household who now have health insurance (except for MaineCare) which covers more than one service

List children in your household who lost health insurance (except for MaineCare) in the last 3 months and why they lost insurance:

List children in your household who can be added to a household member’s State Employee health insurance:

8. Special Conditions

(D Check here if anyone has a disabling condition or is applying for Limited Benefits Program. (There may be special help available to you.)

1 Check here if your child is a member of a Federally recognized American Indian tribe or Alaskan Native. (No premium is required.) Nameoftribe

Is everyone for whom you are applying a U.S, citizen? O ves (No If no, complete the following for everyone who is not a US citizen: Name Document Type Document ID Number | Has he/she lived in US | {s his/her spouse or Since 1996? Yes or parent a veteran or No active-duty member in the US military? Yes

| or No + —

If English is not your first language, what language do you speak? _

Does any child on this application have a parent living outside of the home? 0 Yes 1 No

If yes, I know | will be asked to cooperate with the agency that collects medical support from an absent parent. If | think that cooperating to collect medical support will harm me or my children, | can tell Medicaid and | may not have to cooperate.

Are you asking for help with medical bills incurred in the last 3 months? 0 Yes [No Do you want to apply for Food Stamps? 0 Yes 1) No

9, Signature

Ifyou have to pay a premium, coverage can start either the month the Dept. of Health and Human Services receives this application, or the next month. Please write the name of the month you want coverage to start.

Tunderstand and agree to provide documents to prove what I have stated. 1 understand and agree that the information I have given may be verified by federal, state and local officials or other persons and organizations, If I have given incorrect information, my application may be denied and 1 may be charged with giving false information. 1 understand the questions on this application and the penalty for hiding or giving false information or breaking any of the rules in the penalty warning. I certify under penalty of perjury that my answers, including those concerning citizenship or alien status, are correct and complete for all persons applying for benefits.

If anyone on this application is cligible for Medicaid, | am giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. | am also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent.

Signature of person filling out this form Date BFI-CCO001 (1/14)

Transmittal Number: ME-13-0025MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

MEDICAID APPLICATION SUPPLEMENT

COMPLETE THIS SUPPLEMENT FOR YOURSELF, YOUR SPOUSE/PARTNE! : Tern R AND CHILDREN WHO LIVE WITH YOU AND/OR ANYONE ON YOUR SAME FEDERAL INCOME TAX RETURN IF YOU FILE ONE, IF YOU Di hn MEMBERS WHO LIVE WITH YOU. ONT FILE A TAK RETURN, REMEMBER TO STILL ADD FAMILY T ame ~ APP LAST NAME: APP FIRST NAME: | MI: : i =I AMERICAN INDIANS AND ALASKA NATIVES Names of those with Indian Health Service Coverage: Does Not Receive Indian Health Service Coverage, but is eligible: ; a 7 : OTHER MEDICAL INSURANCE = (IF APPLICABLE, LIST THE HOUSEHOLD MEMBERS THAT CURRENTLY RECEIVE HEALTH COVERAGE) Name: | Company: Policy: | Type: EMPLOYER INSURANCE ae HOUSEHOLD MEMBERS RECEIVING, OR ELIGIBLE FOR, EMPLOYER SPONSORED HEALTH INSUARNCE (NOW OR IN THE NEXT THREE MONTHS) PROVIDING THE SSN IS OPTIONAL FOR PERSONS WHO ARE NOT APPLYING FORMEDICAL COVERAGE aetna aad Name: [ SSN: | Minimal essential coverage? Date when eligible to enroll: | Monthly premium for lowest-cost plan offered: $ T Employer Name: | Employer EIN: Employer Address: Employer Phone: Employer Email: _| Employer Insurance Name: Employee Contact Info: | TAX INFORMATION, APPLICANT (YOU CAN STILL BE ELIGIBLE FOR PROGRAMS EVEN IF YOU DON'T FILE FEDERAL INCOME TAX) A. Will you file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D: B, Will you file jointly with spouse: | Name of spouse: | Roe C, Will you claim dependents on your tax return: Name of dependent 1: | —_ — — ff fern LE oo <n} Name of dependent 2: Name of dependent 3: | | D. Will you be claimed as a dependent on someone's tax return: Name of filer: | DEDUCTIONS, APPLICANT | PSE ENTER AMOUNTS FOR ALL THAT APPLY T Alimony pald: How often? Student loan interest: How often? | Other deductions: How often? Type: | For American Indlans and Alaskan Natives Only | Certain money received can be excluded from income; list any money received from these sources: per capita payments from a tribe that comes from | natural resources, usage rights, leases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance. | How much received? $ How often? | [ = SIGNATURE | | I'M SIGNING THIS APPLICATION UNDER PENALTY OF PERJURY WHICH MEANS I'VE PROVIDED TRUE ANSWERS TO ALL THE QUESTIONS ON THIS FORM TO THE BEST OF MY KNOWLEDGE. I KNOW THAT I MAY BE SUBJECT TO PENALTIES UNDER FEDERAL | LAW IF I PROVIDE FALSE AND OR UNTRUE INFORMATION. | ped Signature of applicant: Date: |

L_ _ __

v, 11/01/2013

Transmittal Number: ME-13-0025MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

TAX INFORMATION, NAME OF PERSON #1 WHO LIVES WITH YOU:

A. Will he/she file Income Tax Next Year (if yes, please answer question

s A-C; if no, skip to question D:

Total Income (list next year’s total income for this person):

8. Will he/she file jointly with spouse: Name of spouse:

C. Will he/she claim dependents on your tax return: Name of dependent 1: —_

Name of dependent 2: Name of dependent 3: 7 a D. Will he/she be claimed as a dependent on someone’s tax return: Name of filer:

DEDUCTIONS, PERSON#1 WHO LIVES WITH YOU - ENTER AMOUNTS FOR ALL THAT APPLY

Allmony paid: How often?

7 I Student loan Interest: [| How often?

Other deductions: | How often?

[i

For American Indians and Alaskan Natives Only

How much received? $

Certain money received can be excluded from income; list any money received from these sources: per capita payments from a tribe that comes from | natural resources, usage rights, leases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance.

How often?

TAX INFORMATION, NAME OF PERSON #2 WHO LIVES WITH YOU:

A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D:

B, Will he/she file jointly with spouse:

Name of spouse:

Total Income (list next year’s total Income for this person):

C. Will he/she clalm dependents on your tax return: Name of dependent 1: Name of dependent 2: Name of dependent 3: D. Will he/she be claimed as a dependent on someone's tax return: Name of filer:

DEDUCTIONS, PERSON #2 WHO LIVES WITH YOU - enter AMOUNTS FOR ALL THAT APPLY

Alimony paid: | How often?

il Student loan interest: How often?

Other deductions: How often?

| Type:

For American Indians and Alaskan Natives Only

How much received? $

Certain money received can be excluded from income; list any money received from these sources: per capita payments from a tribe that comes from natural resources, usage rights, teases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance.

How often?

"TAX INFORMATION, NAME OF PERSON #3 WHO LIVES WITH YOU:

A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D:

B. Will he/she file jointly with spouse:

Name of spouse:

C. Will he/she claim dependents on your tax return:

Name of dependent 2: 1

Name of dependent 1:

Name of dependent 3:

; D. Will he/she be claimed as a dependent on someone's tax return:

Name of filer:

Total Income (list next year’s total Income for this person):

_DEDUCT! IONS, PERSON #3.WHO LIVES WITH YOU -ENTER AMOUNTS FOR ALL THAT APPLY

Alimony paid: | How often?

T

| Student loan interest: | How often?

Other deductions: | How often?

| Type:

For American Indians and Alaskan Natives Only

Certain money recelved can be excluded from income; list any money re

How much received? $

natural resources, usage rights, leases or royalties: payments from natural resou designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance.

ceived from these sources: per capita payments from a tribe that comes from ces, farming, ranching, fishing, leases, or royalties from land

How often?

Transmittal Number: ME-13-0025MM2

Approval Date: December 10, 2013

v. 11/01/2013

Effective Date: October 1, 2013

TAX INFORMATION, NAME OF PERSON #4 WHO LIVES WITH YOU:

A, Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D:

B, Will he/she file jointly with spouse: Name of spouse: 7 C. Will he/she claim dependents on your tax return: Name of dependent 1: Name of dependent 2: Name of dependent 3: | D, Will he/she be claimed as a dependent on someone's tax return: | Name of filer:

Total Income (list next year's total income for this person): DEDUCTIONS, PERSON #4 WHO LIVES WITH YOU - ENTER AMOUNTS FOR ALL THAT APPLY Alimony paid: I How often? | Student loan interest: | How often?

Other deductions: How often? | Type:

— | For American Indians and Alaskan Natives Only |

Certain money received can be excluded from income; list any money received from these sources: per capita payments from a tribe that comes from natural resources, usage rights, leases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance.

How much received? $ How often?

TAX INFORMATION, NAME OF PERSON #5 WHO LIVES WITH YOU:

A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D:

B. Will he/she file jointly with spouse: Name of spouse: _

C. Will he/she claim dependents on your tax return: Name of dependent 1: | Name of dependent 2: Name of dependent 3: a

D. Will he/she be claimed as a dependent on someone's tax return: Name of filer:

Total Income (list next year’s total Income for this person):

DEDUCTIONS, PERSON #5 WHO LIVES WITH YOU - ENTER AMOUNTS FOR ALL THAT APPLY

Alimony paid: How often? | Student loan interest: | How often?

Other deductions: How often? Tee:

For American Indians and Alaskan Natives Only

Certain money recelved can be excluded from income; list any money received from these sources: per capita payments from a tribe that comes from natural resources, usage rights, leases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land | designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance. |

How much received? $ How often?

TAX INFORMATION, NAME OF PERSON #6 WHO LIVES WITH YOU:

A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D:

— = B. Will he/she fite jointly with spouse: | Name of spouse: | C. Will he/she claim dependents on your tax return: Name of dependent 1: i

Name of dependent 2: Name of dependent 3:

D. Will he/she be claimed as a dependent on someone's tax return: Name of filer:

Total Income (list next year’s total income for this person):

DEDUCTIONS, PERSON #6 WHO LIVES WITH YOU - ENTER AMOUNTS FOR ALL THAT APPLY

Alimony paid: | How often? Student loan interest: | How often?

Other deductions: How often? [ Type:

For American Indians and Alaskan Natives Only | Certain money received can be excluded from Income; list any money received from these sources: per capita payments from a tribe that comes from natural resources, usage rights, leases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land | designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance.

How much received? $ How often?

v. 11/01/2013

Transmittal Number: ME-13-0025MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

State of Maine Return'so7

Department of Health and Human Services (DHHS) Application For

MaineCare and Food Supplement Benefits

Application for:

O MaineCare — Full Benefits D Medicare Savings Program Only Oo Low Cost Drugs (DEL) / MaineRx Plus (Buy In)

D MaineCare Limited Benefits Program D Food Supplement Benefits

Do you have a physical or mental health condition that keeps you from working full or part time? O Yes O No

Providing a Social Security number is optional for individuals who are not applying for coverage in any program.

Your name (first, middle initial, last) Maiden Name Social Security number | Sex Birth date (month/day/year) Place of birth Your Medicare claim number (if any) Mailing address: Street, PO Box, or RR (include apartment number, in care of, ete.) Is this a safe delivery address? OYes ONo City State Zip Code Phone

If different from your mailing address, give the address where you actually live:

You need to answer only the questions for the program(s) you are applying for.

For Food Supplement Benefits Only: To file this application now, we need your name (or that of an authorized representative), address and signature. If eligible, your benefits will begin from the date DHHS gets a signed application.

You may be eligible for Food Supplement benefits right away:

¢ — does your monthly income and cash/money in a bank add up to less than your monthly living expense? ¢ is your monthly income less than $150 and cash/money in a bank less than $100? ¢ are you a migrant worker and your income has stopped?

Social Security numbers are used to do computer matches with LR.S., BMV, IFW, the Social Security Administration, Department of Labor, other government agencies and private financial institutions. DHHS and federal officials may check with other sources to prove the information you give.

If you give wrong information, you may be charged with giving false information,

I understand the questions on this form. 1 certify, under penalty of perjury, that all my answers are correct and complete as far as 1 know, including those concerning citizenship and alien status for each person applying for benefits. 1 understand DHHS has the right to collect from other available insurance or from settlement(s) for accidents or injuries whenever MaineCare pays for Medical Expenses.

Signature of person applying Date

Signature of person filling out this form Date

If you have someone who knows your situation, and you want us to contact them to help with this application, please complete the following:

Name. Address,

Telephone For office use only: Received 45" day : Residency ID

Food Supplement Benefit Expedite OYes ONo

Transmittal Number: ME-13-0025MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

For MaineCare and Food Supplement Benefits

ARE YOU: If you live with your spouse: 0 Married Spouse’s name (first, middle initial, last) O Widowed Date of birth Sex Able to work? DYes ONo O Single (month /day/year) O Divorced Place of birth Maiden name O Separated Spouse’s Social Security number

(Check only one box) _ Spouse's Medicare claim number

List other people who live with you and their grade in school if applicable:

Last name First name Middle | Sex Birth - Social Security | Relationship Grade Initial date Number to you level (Optional if not

Requesting Coverage)

Is everyone you are applying for a U.S. citizen? OYes ONo If no, please list their names and Alien Registration Numbers.

Please list place of birth for each person for whom you are requesting assistance

First Name Place of Birth First Name Place of Birth First Name Place of Birth

List monthly household income below:

Source Yourself Your spouse Other family members (who lives with you) | (please list amount and name of member) Social Security $ $ $ SSI $ $ $ Other Income or Pensions $ $ $ (such as railroad retirement, interest, dividends, etc., please explain)

List household earnings for yourself and your spouse (who lives with you): Please provide the last 4 pay stubs or

copies of them (If you are applying for MaineCare only, you are not required to provide verification of carnings at this time, but you may be asked to do so in the future if electronic verification is not possible)

Name Employer’s name and Gross Amount How often | Hours worked phone number earned are you paid each week

Is anyone in your household self-employed? DYes ONo If YES, Who?

Source? How often?

Please provide a copy of your most recent tax return or business records.

List assets for yourself and your spouse (who lives with you), including jointly owned assets:

(Ifyou are applying for Food Supplement Benefits, also list the assets of others in your household)

+ Checking or Savings Account + Credit Union Shares + IRA, 401K, Keogh + Certificate of Deposit + Other Accounts * Profit Sharing + Safety Deposit Box + Assets Owned with Others + Stocks + Annuities _+ Pre aid Burials + Trusts

Name(s) on account | Type of asset Name of Account number Current balance _(see above) bank or institution or value

Transmittal Number: ME-13-0025MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

MEDICAID APPLICATION SUPPLEMENT

COMPLETE THIS SUPPLEMENT FOR YOURSELF, YOUR SPOUSE/PARTN i ‘ H s ER AND CHILDREN WHO LIVE WITH YOU AND/OR ANYONE ON YOUR SAME FEDERAL INCOME TAX RETURN IF YOU FILE ONE. IF YOU D MEMBERS WHO LIVE WITH YOU. U DON'T FILE A TAX RETURN, REMEMBER TO STILL ADD FAMILY APP LAST NAME: APP FIRST NAME: | MI: | : AMERICAN INDIANS AND ALASKA NATIVES Names of those with Indian Health Service Coverage: Does Not Receive Indian Health Service Coverage, but is eligible: oO nl : : OTHER MEDICAL INSURANCE : (IF APPLICABLE, LIST THE HOUSEHOLD MEMBERS THAT CURRENTLY RECEIVE HEALTH COVERAGE) Mane: Company: Policy: Type: | : EMPLOYER INSURANCE HOUSEHOLD MEMBERS RECEIVING, OR ELIGIBLE FOR, EMPLOYER SPONSORED HEALTH INSUARNCE (NOW OR IN THE NEXT THREE MONTHS) PROVIDING THE SSN IS OPTIONAL FOR PERSONS WHO ARE NOT APPLYING FORMEDICAL COVERAGE Name: SSN: oe [ Minimal essential coverage? Date when eligible to enroll: | Monthly premium for lowest-cost plan offered: $ | _ — — Employer Name: Employer EIN: = Employer Address: — —— Employer Phone: Employer Email: Employer Insurance Name: Employee Contact Info: TAX INFORMATION, APPLICANT (YOU CAN STILL BE ELIGIBLE FOR PROGRAMS EVEN IF YOU DON’T FILE FEDERAL INCOME TAX) A. Will you file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D: _| B. Will you file jointly with spouse: | Name of spouse: C. Will you claim dependents on your tax return: Name of dependent 1: Name of dependent 2: Name of dependent 3: | = aes — D. Will you be claimed as a dependent on someone's tax return: Name of filer: DEDUCTIONS, APPLICANT ae : ENTER AMOUNTS FOR ALL THAT APPLY Alimony paid: How often? | student loan interest: ] How often? Other deductions: How often? | type: _| | For American Indians and Alaskan Natives Only Certain money received can be excluded from income; list any money received from these sources: per capita payments from a tribe that comes from | natural resources, usage rights, leases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land | designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance. | | How much received? $ How often? 2 SIGNATURE | 1 IM SIGNING THIS APPLICATION UNDER PENALTY OF PERJURY WHICH MEANS I'VE PROVIDED TRUE ANSWERS TO ALL THE QUESTIONS ON THIS FORM TO THE BEST OF MY KNOWLEDGE. I KNOW THAT I MAY BE SUBJECT TO PENALTIES UNDER FEDERAL LAW IF I PROVIDE FALSE AND OR UNTRUE INFORMATION. _ ee | Signature of applicant: Date: oo ee a

v. 11/01/2013

Transmittal Number: ME-13-0025MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D:

TAX INFORMATION, NAME OF PERSON #1 WHO LIVES WITH YOU: =

B. Will he/she file jointly with spouse: Name of spouse:

C. Will he/she claim dependents on your tax return: Name of dependent 1: oe

Name of dependent 2: Name of dependent 3:

D. Will he/she be claimed as a dependent on someone's tex retum: Name of fiter: _

Total Income (list next year’s total income for this person):

DEDUCTIONS, PERSON#1 WHO LIVES WITH YOU - enrer AMOUNTS FOR ALL THAT APPLY

Alimony paid: | How often? Student loan interest: | How often?

Other deductions: | How often? | Type:

For American Indians and Alaskan Natives Only

Certain money received can be excluded from income; list any money received from these sources: per capita payments from a tribe that comes from natural resources, usage rights, leases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance.

How much received? $ How often?

TAX INFORMATION, NAME OF PERSON #2 WHO LIVES WITH YOU:

A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D:

B. Will he/she file jointly with spouse: Name of spouse:

C. Will he/she claim dependents on your tax return: Name of dependent 1:

Name of dependent 2: Name of dependent 3: 7 —_ |b. wil he/she be claimed as a dependent on someone's tax return: Name of filer:

Total Income (list next year’s total Income for this person):

DEDUCTIONS, PERSON #2 WHO LIVES WITH YOU - ENTER AMOUNTS FOR ALL THAT APPLY

Alimony paid: | How often? Student loan interest: How often?

Other deductions: How often? | Type:

For American Indlans and Alaskan Natives Only

Certain money received can be excluded from income; list any money received from these sources: per capita payments from a tribe that comes from natural resources, usage rights, leases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indlan trust land by the Dept. of Interior; and money from selling things that have cultural significance.

How much received? $ How often?

TAX INFORMATION, NAME OF PERSON #3 WHO LIVES WITH YOU:

A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D:

| B. Will he/she file jointly with spouse: Name of spouse: | i -— 1 C. Will he/she claim dependents on your tax return: Name of dependent 1: Name of dependent 2: Name of dependent 3:

D. Will he/she be claimed as a dependent on someone's tax return: Name of filer:

Total Income (list next year’s total income for this person):

DEDUCTIONS, PERSON #3 WHO LIVES WITH YOU -ENTER AMOUNTS FOR ALL THAT APPLY

Alimony paid: | How often? Student loan interest: | How often?

Other deductions: How often? | Type:

For American Indians and Alaskan Natives Only

Certain money received can be excluded from income; list any money received from these sources: per capita payments from a tribe that comes from natural resources, usage rights, teases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance.

How much received? $ _ How often?

|

v. 11/01/2013

Transmittal Number: ME-13-0025MM2 Approval Date: December 10, 2013 Effective Date: October 1, 2013

TAX INFORMATION, NAME OF PERSON #4 WHO LIVES WITH YOU:

A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D:

B. Will he/she file jointly with spouse:

Name of spouse:

C. Will he/she claim dependents on your tax return:

Name of dependent 1:

Name of dependent 2:

Name of dependent 3:

D. Will he/she be claimed as a dependent on someone's tax return:

Name of filer:

Total Income (list next year’s total income for this person):

DEDUCTIONS, PERSON #4 WHO LIVES WITH YOU - ENTER AMOUNTS FOR ALL THAT APPLY

| Alimony paid: How often?

Student loan interest:

How often?

| Other deductions: How often?

Type:

For American Indians and Alaskan Natives Only

How much received? $

How often?

Certain money received can be excluded from income; list any money received from these sources: per capita payments from a tribe that comes from natural resources, usage rights, leases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Dept. of Interlor; and money from selling things that have cultural significance.

TAX INFORMATION, NAME OF PERSON #5 WHO LIVES WITH YOU:

A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D:

B. Will he/she file jointly with spouse:

Name of spouse:

C, Will he/she claim dependents on your tax return:

Name of dependent 1:

Name of dependent 2:

Name of dependent 3:

D. Will he/she be claimed as a dependent on someone's tax return:

Name of filer:

Total Income (list next year’s total income for this person): | DEDUCTIONS, PERSON #5 WHO LIVES WITH YOU - ENTER AMOUNTS FORALL THAT APPLY

Alimony paid: How often? | student loan interest: | How often?

Other deductions: 7 How often? Type:

For American Indians and Alaskan Natives Only

Certain money received can be excluded from income; list any money received from these sources: per capita payments fram a tribe that comes from natural resources, usage rights, leases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from fand

designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance.

How much received? $ How often?

TAX INFORMATION, NAME OF PERSON #6 WHO LIVES WITH YOU:

A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D: 7 | B. Will he/she file jointly with spouse: | Name of spouse: 7 a _ Z C. Will he/she claim dependents on your tax return: Name of dependent 1: _ | Name of dependent 2: “| Name of dependent 3:

D. Wil he/she be claimed as a dependent on someone's tax return: Name of filer:

Total Income (list next year’s total income for this person):

DEDUCTIONS, PERSON #6 WHO LIVES WITH YOU - ENTER AMOUNTS FOR ALL THAT APPLY

Alimony paid: How often?

Student loan interest:

How often?

Other deductions: How often?

| te:

For American Indians and Alaskan Natives Only

| How much received? $

How often?

Certain money received can be excluded from income; list any money received from these sources: per capita payments from a tribe that comes from | natural resources, usage rights, leases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance.

Transmittal Number: ME-13-0025MM2

Approval Date: December 10, 2013

v. 11/01/2013

Effective Date: October 1, 2013

Table of Contents: State Plan Amendment ME 13-028MM5 1. Approval Letter 2. Superseding Page Information 3. CMS Form 179 4. State Plan Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 20, 2014

Mary Mayhew, Commissioner

Department of Health and Human Services 11 State House Station

Augusta, Maine 04333-0011

RE: Maine 13-0028-MMS5

Dear Commissioner Mayhew:

Enclosed is an approved copy of Maine’s State Plan Amendment (SPA) 13-0028-MMS5, which was submitted to CMS on September 16, 2013. SPA 13-0028-MM5, approved on December 13, 2013, updates residency language in the State Plan and affirms that the state meets the requirements of 42 CFR §435.403 and provides Medicaid to otherwise eligible residents of the state, including residents who are

absent from the state under certain conditions. The effective date of this SPA is January 1, 2014.

Enclosed is a copy of the new State Plan page to be incorporated within a separate section at the back of Maine’s approved State Plan:

e S88, pages | - 4

In addition, enclosed is a summary of State Plan pages which are superseded by ME 13-0028-MM5; this document should be incorporated into a separation section in the front of the State Plan.

If you have any questions regarding this SPA, please contact Kathryn Holt, Maine State Lead, at 617/565- 1246, or at kathryn.holt@cms.hhs.gov.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

cc: Stefanie Nadeau, Director, Office of Maine Care Services

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

ME-13-0028 MMS

STATE:

Maine

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

$88 Non-Financial Eligibility- State Residency Attachment 2.6-A, Page 3

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

(New) Attachment 2.6-A, Page 3, TN 13-0029 MM6

OFFICIAL

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Maine

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-Y¥-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-13-0028

Proposed Effective Date 01/01/2014 (mn/dd/yyyy)

Federal Statute/Regulation Citation 42 CFR 435.403

Federal Budget Impact

Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $0.00

Subject of Amendment To ensure compliance with the Affordable Care Act

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

Comments of Governor's office received Describe:

No reply received within 45 days of submittal

Other, as specified Describe: Commissioner, Maine Department of Health and Human Services

Signature of State Agency Official Submitted By: Reinhold Bansmer Last Revision Date: Dec 12, 2013 Submit Date: Sep 16, 2013

DATE RECEIVED: 9/16/13

DATE APPROVED:

12/13/13

PLAN APPROVED — ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL:

1/1/14

SIGNATURE OF REGIONAL OFFICIAL:

TYPED NAME

Richard R. McGreal

TITE

Associate Regional Administrator, Division of Medicaid and Children's Health Operations, Boston Regional Office

OFFICLAL

ord

CCmMsS Medicaid Eligibility

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

Non-Financial Eligibility S88 State Residency

42 CFR 435.403

State Residency

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

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

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

[H Intends to reside in the state, including without a fixed address, or [m] Entered the state with a job commitment or seeking employment, whether or not currently employed.

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

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

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

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

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

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

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

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

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

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

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

TN No. 13-0028-MM5 Approval Date: 12/13/13 Effective Date: 1/1/14 Maine $88-1

OFFICIAL

CcCmMs Medicaid Eligibility

[] Otherwise meet the requirements of 42 CFR 435.403.

TN No. 13-0028-MM5 Approval Date: 12/13/13 Effective Date: 1/1/14 Maine $88-2

OPRICIAL

a Medicaid Eligibility

@ Yes

C No

Meet the criteria specified in an interstate agreement.

[M) The state has interstate agreements with the following selected states:

KK) Alabama & Mlinois & Montana R) Rhode Island [K) Alaska {] Indiana RX] Nebraska ) South Carolina Arizona & lowa ] Nevada South Dakota

Arkansas

Kansas

) New Hampshire

Tennessee

] California { Kentucky & New Jersey Texas ) Colorado Louisiana I New Mexico Utah KK) Connecticut Maine 0 New York &] Vermont Delaware —) Maryland North Carolina Virginia

District of Columbia

EX Massachusetts

&] North Dakota

&] Washington

Florida & Michigan I] Ohio West Virginia Georgia & Minnesota ) Oklahoma I] Wisconsin &) Hawaii {] Mississippi Oregon (1 Wyoming Idaho & Missouri &] Pennsylvania

The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency

status and criteria for resolving disputed residency of individuals who (select all that apply):

K] Are IV-E eligible

CD Are in the state only for the purpose of attending school

OC Are out of the state only for the purpose of attending school

Retain addresses in both states

{K] Other type of individual

Name of Type

Description

+

Non-IV-E Adopted children

Maine applies the same criteria and procedures of the

ICAMA Interstate Agreement to children who are not 1V-E » ¢

eligible.

@ Yes

C No

The state has a policy related to individuals in the state only to attend school.

TN No. 13-0028-MM5 Maine

Approval Date: 12/13/13

$88-3

Effective Date: 1/1/14

ageiclAL

a Medicaid Eligibility

Provide a description of the policy:

An individual under age 21 who is a full-time student in the State of Maine will not be considered a resident of Maine if all

of the following conditions exist:

- neither of the individual's parents reside in the State of Maine;

- the individual is claimed as a tax dependent by someone who resides in a state other than Maine; and - the individual is applying for coverage on his or her own behalf.

[®] Otherwise meet the criteria of resident, but who may be temporarily absent from the state. The state has a definition of temporary absence, including treatment of individuals who attend school in another state.

@ Yes C No

Provide a description of the definition:

An individual can be temporarily or voluntarily absent from the State of Maine provided the individual intends to return once the purpose of the absence has been accomplished, unless another state has determined the individual is a

resident there.

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

TN No. 13-0028-MM5 Approval Date: 12/13/13 Effective Date: 1/1/14 Maine $88-4

Table of Contents State/Territory Name: Maine State Plan Amendment (SPA) #: 13-0029-MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

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

JFK Federal Building. Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 20, 2014

Mary Mayhew, Commissioner Department of Health and Human Services 11 State House Station

Augusta, Maine 04333-0011

RE: Maine 13-0029-MM6

Dear Commissioner Mayhew:

Enclosed is an approved copy of Maine’s State Plan Amendment (SPA) 13-0029-MM6, which was submitted to CMS on September 13, 2013. SPA 13-0029-MM6, approved on December 10, 2013, incorporates the citizenship regulations, specifies reasonable opportunity period options, and specifies policy options related to eligible non-citizens into Maine’s State Plan in accordance with the Social

Security Act and regulations at 42 CFR Part 435. The effective date of this SPA is January 1, 2014.

Enclosed is a copy of the new State Plan page to be incorporated within a separate section at the back of Maine’s approved State Plan:

e $89, pages | -3

In addition, enclosed is a summary of State Plan pages which are superseded by ME 13-0029-MM6; this document should be incorporated into a separation section in the front of the State Plan.

If you have any questions regarding this SPA, please contact Kathryn Holt, Maine State Lead, at 617/565- 1246, or at kathryn.holt@cms.hhs.gov.

Sincerely /s/

Richard R. McGreal Associate Regional Administrator

cc: Stefanie Nadeau, Director, Office of Maine Care Services

State/Territory name: Maine Submitted By: Reinhold Bansmer Last Revision Date: Nov 8, 2013 Submit Date: Sep 13, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. ME-13-0029 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(a)(46)(B), 8 U.S.C. 1611, 1612, 1613, and 1641, 1903(v)(2),(3) and (4), 42 CFR 435.4, 42 CFR 435.406, 4 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment SPA changes to ensure compliance with the Affordable Care Act. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Commissioner, Department of Human Services Signature of State Agency Official Page 1 of 2 ME.0318.R00.00 - Jan 01, 2014 03/13/2014 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

DATE RECEIVED:

DATE APPROVED:

PLAN APPROVED – ONE COPY ATTACHED EFFECTIVE DATE OF APPROVED MATERIAL:

SIGNATURE OF REGIONAL OFFICIAL: TYPED NAME Richard R. McGreal TITLE Associate Regional Administrator, Division of Medicaid and Children's Health Operations, Boston Regional Office 9/13/13 12/10/13 1/1/14 /s/

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

ME-13-0029 MM6 STATE:

Maine

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S89 Non-Financial Eligibility- Citizenship and Non-Citizen Eligibility Attachment 2.6-A, Page 2 Attachment 2.6-A, Page 2a (Deleted) Attachment 2.6-A, Page2b (Deleted) Attachment 2.6-A, Page 3

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

(New) Attachment 2.6-A, Page 2, TN 09-008 Attachment 2.6-A, Page 2a, TN 09-008 Attachment 2.6-A, Page2b, TN 09-008 Attachment 2.6-A, Page 3, TN 09-008

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility Citizenship and Non-Citizen Eligibility S89 1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4) 42 CFR 435.4 42 CFR 435.406 42 CFR 435.956 Citizenship and Non-Citizen Eligibility The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status. ✔ The state provides Medicaid eligibility to otherwise eligible individuals: ■ Who are citizens or nationals of the United States; and

■ Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and ■ Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

■ The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. Yes No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. Yes No The date benefits are furnished is: First day of month of application containing the declaration of citizenship or immigration status. The date of application containing the declaration of citizenship or immigration status. The date the reasonable opportunity notice is sent. Other date, as described: TN No. 13-0029-MM6 Maine Approval Date: 12/10/13 S89-1 Effective Date: 1/1/14

Page 2 of 3 Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613). Yes No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act. Yes No Pregnant women Individuals under age 21: Individuals under age 21 Individuals under age 20 Individuals under age 19 An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. ■ An individual is considered to be lawfully present in the United States if he or she: ■ 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c); 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ■ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ■ Granted employment authorization under 8 CFR 274a.12(c); ■ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ■ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ■ Granted Deferred Action status; ■ Granted an administrative stay of removal under 8 CFR 241; ■ Beneficiary of approved visa petition who has a pending application for adjustment of status; ■ 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who - Has been granted employment authorization; or ■ Is under the age of 14 and has had an application pending for at least 180 days; ■ TN No. 13-0029-MM6 Maine Approval Date: 12/10/13 S89-2 Effective Date: 1/1/14

Page 3 of 3 Medicaid Eligibility 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); 10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN: ✔ Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613; ■ Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b). ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 13-0029-MM6 Maine Approval Date: 12/10/13 S89-3 Effective Date: 1/1/14

_____________________________________________________________________________

Table of Contents State/Territory Name: Maine State Plan Amendment (SPA) #:13-038 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

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

JFK Federal Building, Government Center or Paved xy

CENTERS FOR MEDICARE & MEDICAID SERVICES Room 2275 Oo c

Boston, Massachusetts 02203

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 11, 2014

Mary Mayhew, Commissioner Department of Health and Human Services 11 State House Station

Augusta, Maine 04333-0011

Re: Maine SPA TN 13-038 Dear Commissioner Mayhew:

We are pleased to enclose a copy of approved Maine State Plan Amendment (SPA) No. 13-038 with an effective date of December 20, 2013. This SPA transmitted a proposed amendment to your approved Title XIX State plan to update eligibility criteria by adding Child and Adolescent Needs and Strengths (CANS) assessment to eligibility criteria for Targeted Case Management services.

If there are questions, please contact Joyce Butterworth at (617) 565-1220 or by e-mail at Joyce.Butterworth@cms.hhs.gov.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

Enclosure/s

ce: Stephanie Nadeau, Director, Office of Maine Care Services

/s/ /s/

N

Supplement | to Attachment 3.1-A Page la State Plan Title XIX of the Social Security Act State/Territory: Maine TARGETED CASE MANAGEMENT SERVICES

[Children with Chronic Health Conditions]

Target Group (42 Code of Federal Regulations 441.18(8)(i) and 441.18(9)): OFFICIAL

Children with Chronic Health Conditions must meet the following criteria:

Eligibility Criteria for Children with Chronic Medical Conditions

A child who is infected with the human immunodeficiency virus (HIV), as determined by a positive HIV antibody or antigen test, or who has a diagnosis of HIV disease or AIDS; OR A child who has: a. been diagnosed with an autoimmune disease, diabetes, respiratory disorder, a neurological disorder, brain injury or other chronic condition specifically recognized by the Department or its authorized agent;

AND three (3) or more documented functional limitations, including:

Vocational Impairment in vocational functioning as manifested by (1) an inability to be consistently employed at a self-sustaining level or (2) an ability to be employed only with extensive supports.

Education Impairment in educational functioning as manifested by an inability to establish and pursue educational goals within a normal time frame or without extensive supports.

Instrumental Activities of Daily Living (IADL)

Impairment in IADL functioning as manifested by an inability to consistently and independently accomplish home management tasks, including household meal preparation, washing clothes, grocery shopping and budgeting.

Social or Interpersonal Impairment in social or interpersonal functioning as manifested by an inability to independently develop or maintain social relationships, or to independently participate in social or recreational activities.

Community Impairment in community functioning as manifested by a pattern of significant community disruption, including family disruption or social unacceptability or inappropriateness.

Self-care, Independent Living or Activities of Daily Living Impairment in self-care or independent living as manifested by an inability to consistently perform the range of practical daily living tasks required for basic functioning in the community, including: - Bed mobility, transfer, locomotion, eating, toilet use, bathing, and dressing - Grooming, hygiene, and meeting nutritional needs

TN 13-038 Approval Date: 03/11/2014 Effective Date 12/20/13 Supersedes TN:09-01 la

Les)

Supplement | to Attachment 3.1-A

Page lb State Plan Title XIX of the Social Security Act State/Territory: Maine TARGETED CASE MANAGEMENT SERVICES [Children with Chronic Health Conditions] OFFICIAT

- Care of personal business affairs

- Transportation and care of residence

- Procurement of medical, legal, and housing services

- Recognition and avoidance of common dangers or hazards to self and possessions.

OR

A Child who has:

a. adiagnosed physical condition or the presence of a documented history by a professional approved by the Department of prenatal, perinatal, neonatal. or early physical developmental events or conditions suggestive of damage to the central nervous system or of later atypical physical development, such as, but not limited to, cerebral palsy, meningitis, heart defects, or bronchiopulmonary dysplasia which, without intervention, has a high probability of resulting in physical developmental delay,

AND .

b. significant impairment or limitation in adaptive functioning according to criteria as established by the Department and determined by a qualified professional approved by the Department.

xX Target group Includes individuals transitioning to a community setting and are consistent with all federal guidelines. Case-management services will be made available for up to 30 days consecutive days of a covered stay In a medical Institution. Reimbursement is made to community- based case managers and not the medical institution for this service. The target group does not include Individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions). (State Medicaid Directors Letter (SMDL). July 25, 2000)

Areas of State in which services will be provided (§1915(g)(1) of the Act): Entire State _] Only in the following geographic area [Specific areas]

Comparability of services (§§1902(a)(10)(B)and 1915(g)(1)) [_] Services are provided in accordance with §1092(a)(10)(B) of the Act. [X] Services are not comparable in amount duration and scope ($1915(g)(1))

Definition of Services (42 CFR 440.169): Definition of services 42 CFR 440.169): Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, In gaining access to needed medical, social, educational and other services. Targeted Case Management Includes the following assistance

TN 13-038 Approval Date: 03/11/2014 Effective Date 12/20/13 Supersedes TN:09-01lla

Supplement | to Attachment 3.1-A Page Ic State Plan Title XIX of the Social Security Act

State/Territory: Maine OFFI CIAL

TARGETED CASE MANAGEMENT SERVICES ~~

[Children with Chronic Health Condition]

«+ Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities - include

e taking client history;

e identifying the individual’s needs and completing related documentation; and

e gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual;

The comprehensive assessment must be completed within the first thirty (30) days of Initiation of services and reassessment must minimally occur on an annual basis (or as a change in the member's needs occur).

** Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that

e specifies the goals and actions to address the medical, social, educational , and other services needed by the Individual:

e Includes activities such as ensuring the active participation of the eligible Individual, and working with the Individual (or the Individual's authorized health care decision maker) and others to develop those goals; and

e Identifies a course of action to respond to the assessed needs of the eligible individual;

¢* Referral and related activities (such as scheduling appointments for the individual) to help the eligible Individual obtain needed services including e activities that help link the Individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and

** Monitoring and follow-up activities are consistent with federal regulations and include:

e activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible Individual's needs, and which may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary. Plans must be monitored at least every 90 days, or as the member's needs change and any change in the plan must be documented in the member's file. Monitoring will be conducted to determine whether the following conditions are met:

= services are being furnished in accordance with the individual's care plan; ™ services in the care plan are adequate: and = changes in the needs or status of the individual are reflected in the care plan.

TN 13-038 Approval Date: 03/11/2014 Effective Date 12/20/13 Supersedes TN:09-01 1a

Supplement | to Attachment 3.1-A

Page ld State Plan Title XIX of the Social Security Act

State/Territory: Maine atch AL TARGETED CASE MANAGEMENT SERVICES. ! # | — = ~~

[Children with Chronic Health Conditions]

Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.

[>X] Case management includes contacts with non-eligible individuals that are directly related to identifying the eligible individual's needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible

individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible Individual's needs. (42 CFR 440.169(e))

Qualifications of providers (42 CFR 441.18(a)(v) and 42 CFR 441.18(b)): Provider qualifications are as follows:

Staff Qualifications Comprehensive Case Manager Qualifications

a. Staff must have a minimum of a:

1. Bachelor's Degree from an accredited four (4) year institution of higher learning with a specialization in psychology, mental health and human services, behavioral health, behavioral sciences, social work, human development, special education, counseling, rehabilitation, sociology, nursing or closely related field,

OR

2. Graduate of an accredited graduate school with a Master's Degree in social work, education, psychology, counseling, nursing or closely related field, OR Bachelor's Degree from an accredited four (4) year institution of higher learning in an unrelated field and at least one (I ) year of full-time equivalent relevant human services experience, OR 4. Staff who were employed at the time this rule goes into effect (8/112009) as a case manager

providing services under the former subsections will be considered qualified.

vs)

Freedom of choice 42 CFR 441.18(a)(1): The State assures that the provision of case management services will not restrict an Individual's free choice of providers In violation of section 1902(a)(23) of the Act.

1. Eligible Individuals will have free choice of any qualified Medicaid provider within the specified geographic area Identified In this plan.

2. Eligible Individuals will have free choice of any qualified Medicaid providers of other medical care under the plan.

TN 13-038 Approval Date: 03/11/2014 Effective Date 12/20/13 Supersedes TN:09-01 la

Supplement | to Attachment 3.1-A Page le State Plan Title XIX of the Social Security Act State/Territory: Maine ATTIICT AL TARGETED CASE MANAGEMENT SERVICES >. = — — ~ ~~ [Children with Chronic Health Conditions]

Freedom of Choice Exception (§1915(g)(1) and 42 CFR 441.18(b)):

_] Target group consists of eligible Individual with developmental disabilities or with chronic mental Illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that Individuals with developmental disabilities or with chronic mental illness receive needed services: [Identify any limitations to be imposed on the providers and specify how these limitations enable providers to ensure that individuals within the target groups receive needed services.]

Access to Services (42 CFR 441.18(a)(2). 42 CFR 441.18(a)(3). 42 CFR 441.18(a)(6): The State assures the following:

e Case management (including targeted case management) services will not be used to restrict an Individual's access to other services under the plan.

e Individuals will not be compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management) services; and

e Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan.

Payment (42 CFR 441.18(a)(4)):

Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entitles under other program authorities for this same purpose.

Case Records 42 CFR 441.18(a)(7)):

Providers maintain case records that document for all Individuals receiving case management as follows: (i)The name of the Individual; (ii) The dates of the case management services; (iii)The name of the provider agency (if relevant) and the person providing the case management service; (iv) The nature, content, units of the case management services received and whether goals specified In the care plan have been achieved; (v) Whether the Individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan.

Limitations:

Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440.169 when the case management activities are an integral and Inseparable component of another covered Medicaid service (State Medicaid Manual (SMM) 4302.F).

Case management does not include, and Federal Financial Participation (FFP) Is not available In expenditures for, services defined in §440.169 when the case

TN 13-038 Approval Date: 03/11/2014 Effective Date 12/20/13 Supersedes TN:09-01la

Supplement | to Attachment 3.1-A Page If State Plan Title XIX of the Social Security Act

State/Territory: Maine OFFICIAL

TARGETED CASE MANAGEMENT SERVICES ~~

[Children with Chronic Health Conditions]

management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible Individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program: assessing adoption placements; recruiting or interviewing potential foster care parents: serving legal papers; home investigations; providing transportation ; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c))

FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that is included in an Individualized education program or individualized family service plan consistent with §1903(c) of the Act. ($§1902(a)(25) and 1905(c))

[Specify any additional limitations.]

TN 13-038 Approval Date: 03/11/2014 Effective Date 12/20/13 Supersedes TN:09-01 1a

Supplement | to Attachment 3.1-A Page 2a State Plan Title XIX of the Social Security Act

State/Territory: Maine norota TARGETED CASE MANAGEMENT SERVICES “2 Eh LU AL

[Members Experiencing Homelessness]

Target Group 42 Code of Federal Regulations 441.1818)(1) and 441.1819)):

Members Experiencing Homelessness must meet the following criteria: Members experiencing homelessness must meet the following Eligibility Criteria to be eligible for TCM under this Section. A member who; 1. currently resides or has in the past ninety (90) days resided in an emergency shelter in the State of Maine, OR does not otherwise have a permanent address, residence, or facility in which they could reside, AND requires treatment or services from a variety of agencies and providers to meet the individual's medical, social, educational, and other needs, AND 4. will access needed services only if assisted by a qualified targeted comprehensive case manager who, in accordance with the individual plan of care, locates, coordinates, and regularly monitors the services. 5. Additionally members experiencing homelessness must meet one or more of the following criteria to be eligible for TCM under this section; a. is in need of immediate medical care, OR b. is in need of an immediate crisis evaluation or mental health assessment to address a behavioral health issue, OR c. has acurrent. medical or mental health condition and is at risk of losing or has lost

access to medically necessary services, OR

d. has an immediate need for medications to address an existing medical and/or behavioral health condition, OR

e. is demonstrating physical or mental impairment such that services are necessary to improve, restore or maintain health and well-being, OR

f. has experienced immediate or recent trauma and is demonstrating a need for assistance with gaining and coordinating access to necessary care and services appropriate to their

N

os)

needs.

X] Target group includes individuals transitioning to a community setting and are consistent with all federal guidelines. Case-management services will be made available for up to 30 days consecutive days of a covered stay in a medical institution. Reimbursement is made to community-based case managers and not the medical institution for this service. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or Individual between ages 22 and 64 who are served in Institutions for Mental Disease or Individuals

TN 13-038 Approval Date: 03/11/2014 Effective Date 12/20/13 Supersedes TN:09-01la

Supplement | to Attachment 3.1-A Page 2b State Plan Title XIX of the Social Security Act

State/Territory: Maine Fas L TARGETED CASE MANAGEMENT SERVICES ~~ FFICIAI

[Members Experiencing Homelessness]

who are inmates of public institutions). (State Medicaid Directors Letter (SMDL), July 25, 2000) Areas of State in which services will be provided (§1915(g)(1) of the Act): x] Entire State Only in the following geographic areas: [Specify areas]

Comparability of services (§§1902(a)(10)(B) and 1915(g)(1)) __ Services are provided in accordance with §1902(a)(10)(B) of the Act. XX]__ Services are not comparable in amount duration and scope (§1915(g)(1)).

Definition of services (42 CFR 440.169): Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services. Targeted Case Management includes the following assistance: ** Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include e taking client history; e identifying the individual’s needs and completing related documentation; and e gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual;

The comprehensive assessment must be completed within the first thirty (30) days of initiation of services and reassessment must minimally occur on an annual basis (or as a change in the member’s needs occur). ** Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that e specifies the goals and actions to address the medical, social, educational, and other services needed by the individual; e includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual’s authorized health care decision maker) and others to develop those goals; and

e identifies a course of action to respond to the assessed needs of the eligible individual;

“* Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including

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State/Territory: Maine Opel CLAL TARGETED CASE MANAGEMENT SERVICES “~~ ~~

[Members Experiencing Homelessness]

3. Bachelor's Degree from an accredited four (4) year institution of higher

learning in an unrelated field and at least one (1) year of full-time equivalent

relevant human services experience,

OR

4. Staff who were employed at the time this rule goes into effect (8/1/2009) as a case manager providing services under the former subsections will be considered qualified.

Freedom of choice (42 CFR 441.18(a)(1): The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act. 1. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified In this plan. 2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan.

Freedom of Choice Exception §1915(g)(1) and 42 CFR 441.18(b)):

[_] Target group consists of eligible individuals with developmental disabilities or with chronic mental Illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental Illness receive needed services: [Identify any limitations to be imposed on the providers and specify how these limitations enable providers to ensure that Individuals within the target groups receive needed services.]

Access to Services (42 CFR 441.18(a)(2). 42 CFR 441.18(a)(3). 42 CFR 441.18(a)(6) The State assures the following:

e Case management (including targeted case management) services will not be used to restrict an individual’s access to other services under the plan.

e Individuals will not be compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management) services; and

e Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan.

Payment (42 CFR 441.18(a)(4)):

Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

Case Records (42 CFR 441.18(a)(7))

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[Members Experimenting Homelessness]

Providers maintain case records that document for all individuals receiving case management as follows: (i)The name of the individual; (ii) The dates of the case management services; (iii) The name of the provider agency (if relevant) and the person providing the case management service; (iv) The nature, content, units of the case management services received and whether goals specified In the care plan have been achieved; (v) Whether the individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan.

Limitations:

Case management does not Include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440.169 when the case management activities are an integral and inseparable component of another covered Medicaid service (State Medicaid Manual (SMM) 4302.F).

Case management does not include, and Federal Financial Participation (FFP) Is not available in expenditures for, services defined in §440.169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible Individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c))

FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that Is included In an Individualized education program or individualized family service plan consistent with §1903(c) of the Act. (§§1902(a)(25) and 1905(c))

Services are provided to homeless individuals following a determination of medical need. The services are provided to homeless Individuals who require multiple services to meet multiple assessed needs and they have services that are considered necessary to prevent, alleviate, prevent worsening of or correct conditions that endanger life, cause suffering or pain, result in illness, or interfere with a person's capacity for normal activity.

[Specify any additional limitations.

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State/Territory: Maine OT : TARGETED CASE MANAGEMENT SERVICES 8) ba 1CvAL

[Children with Behavioral Health Disorders]

Target Group (42 Code of Federal Regulations 441.18(8)(i) and 441.18(9)):

Children, ages birth through 20 with behavioral health disorders. The specific

eligibility requirements are as follows:

Children must meet the criteria listed below in subsections I OR 2. In addition children must meet the criteria listed in subsection 3 to be eligible for TCM Services.

1. A child with a completed multi-axial evaluation of an Axis I or Axis II mental health diagnosis(es) as described in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), or a diagnosis described in the most recent version of the Diagnostic Classification of Mental Health and Developmental Disabilities of Infancy and Early Childhood (DC: 0-3). Axis I mental health diagnoses do not include the following: Learning Disabilities (LD) in reading, mathematics, written expression, Motor Skills Disorder, and LD NOS (Learning Disabilities Not Otherwise Specified); Communication Disorders (Expressive Language Disorders, Mixed Receptive Expressive Language Disorder, Phonological Disorder, Stuttering, and Communication Disorder NOS):

OR

2. Achild between birth and five (5) years of age who:

a. is determined by a professional approved by the Department as being at risk of developing a mental health disorder due to known environmental or biological risks using DHHS adopted tools,

AND

b. has significant impairment or limitation in adaptive behavior or functioning according to criteria as established by the Department and determined by a qualified professional approved by the Department.

3. Level of Care Criteria for services will be assessed using either the Children and Adolescent Functional Assessment Scale (CAFAS) - a multi-dimensional rating scale, which assesses a member’s degree of impairment in day-to-day functioning due to emotional, behavioral, psychological, psychiatric, or substance use problems or Child and Adolescent Needs and Strengths (CANS) - a multipurpose tool that assesses the needs and strengths of children and adolescents with mental illness, developmental disabilities/intellectual disabilities, and autism spectrum disorders.

“+ Level of care criteria for services assessed through CAFAS:

a. Case management service is authorized for up to thirty (30) days from the date of the first billed encounter if the eight (8) scale composite CAFAS score is fifty (50) or less.

b. Case management services may continue beyond thirty (30) and up to ninety (90) days from the date of the first billed encounter if the eight (8) scale composite CAFAS score is at least between fifty-one (51) and seventy (70).

ce. Clinical information will be considered in addition to the composite CAFAS scores above as the scores are not the sole criteria for eligibility and review.

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State/Territory: Maine TARGETED CASE MANAGEMENT SERVICES oom ti't CTAL

oe

[Children with Behavioral Health Disorders]

d. Case management services may continue if the 8 scale CAFAS score is above seventy (70). Service continuation will be dependent upon clinical information submitted.

“* Level of care criteria for services assessed through the CANS:

a. Case management service is authorized for up to ninety (90) days from the date of the first billed encounter if the assessment scores are 2 or higher for both the "Behavioral/Emotional needs" AND "Life Domain Functioning" sections of the CANS- PC, the CANS-MH or the CANSAT-MH.

b. Clinical information will be considered in addition to the CANS scores as the scores are not the sole criteria for eligibility and review.

c. Case management service may continue beyond ninety (90) days dependent on clinical information submitted.

X]Target group includes Individuals transitioning to a community setting and are consistent with all federal guidelines. Case-management services will be made available for up to 30 days consecutive days of a covered stay in a medical institution. Reimbursement is made to community-based case managers and not the medical institution for this service. The target group does not include individuals between ages 22 and 64 who are served In Institutions for Mental Disease or individuals who are inmates of public institutions). (State Medicaid Directors Letter (SMDL), July 25, 2000)

Areas of State in which services will be provided (§1915(g)(1) of the Act): XX] Entire State [] Only In the following geographic areas: [Specify areas]

Comparability of services (§$1902(a)(10)(B) and 1915(g)(1) [_] Services are provided in accordance with §1902(a)(10)(B) of the Act. [X] Services are not comparable In amount duration and scope (§1915(g)(1)).

Definition of services (42 CFR 440.169): Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, In gaining access to needed medical, social, educational and other services. Targeted Case Management includes the following assistance:

“* Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include e taking client history;

e Identifying the individual's needs and completing related documentation; and

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[Children with Behavioral Health Disorders]

e gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual;

The comprehensive assessment must be completed within the first thirty (30) days of initiation of services and reassessment must minimally occur on an annual basis (or as a change in the member's needs occur).

** Development (and periodic revision) of a specific care plan that is based on the

Information collected through the assessment that

e specifies the goals and actions to address the medical, social, educational, and other services needed by the Individual:

e Includes activities such as ensuring the active participation of the eligible Individual, and working with the individual (or the Individual's authorized health care decision maker) and others to develop those goals; and

e identifies a course of action to respond to the assessed needs of the eligible Individual;

“* Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including

e activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified In the care plan; and

** Monitoring and follow-up activities are consistent with federal regulations and include: © activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible Individual's needs, and which may be with the individual, family members, service providers, or other entitles or individuals and conducted as frequently as necessary. Plans must be monitored at least every 90 days, or as the member's needs change and any change in the plan must be documented in the member's file. Monitoring will be conducted to determine whether the following conditions are met: © services are being furnished In accordance with the individual's care plan; © services in the care plan are adequate; and © changes in the needs or status of the Individual are reflected in the care plan. Monitoring and follow-up activities Include making necessary adjustments in the care plan and service arrangements with providers.

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[Children with Behavioral Health Disorders]

Case management Includes contacts with non-eligible individuals that are directly related to identifying the eligible Individual's needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible Individual in obtaining services: providing case managers with useful feedback, and alerting case managers to changes in the eligible individual's needs.

(42 CFR 440.169(e))

Qualification of providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)): Provides qualifications are as follows:

Staff Qualifications

Comprehensive Case Manager Qualifications a. Staff must have a minimum of a:

1. Bachelor’s Degree from an accredited four (4) year institution of higher learning with a specialization in psychology, mental health and human services, behavioral health, behavioral sciences, social work, human development, special education, counseling, rehabilitation, sociology, or nursing or closely related field,

OR

2. Graduate of an accredited graduate school with a Master’s Degree on social

work , education, psychology, counseling, nursing or closely related field,

OR

Bachelor's Degree from an accredited four (4) year institution of higher

learning in an unrelated field and at least one (I) year of full-time equivalent

relevant human services experience,

OR

4. Staff who were employed at the time this rule goes into effect (8/1/2009) as a case manager providing services under the former subsections will be considered qualified.

we

Freedom of choice (42 CFR 441.18(a)(1) The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of section 1902(a)(23) of the Act. 1. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan. 2. Eligible Individuals will have free choice of any qualified Medicaid providers of other medical care under the plan.

Freedom of Choice Exception (§1915(g)(1) and 42 CFR 441.18(b)):

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State/Territory: Maine qnaecnat TARGETED CASE MANAGEMENT SERVICES. ! 1G TAL

[Children with Behavioral Health Disorders]

a Target group consists of eligible individuals with developmental disabilities or with chronic mental Illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental Illness receive needed services: [Identify any limitations to be imposed on the providers and specify how these limitations

enable providers to ensure that individuals within the target groups receive

needed services. ]

Access to Services 42 CFR 441 .18(a)(2) 42 CFR 441. 18(a)(3). 42 CFR 441.18(a)(6): The State assures the following:

e Case management (including targeted case management) services will not be used to restrict an Individual's access to other services under the plan.

e Individuals will not be compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management) services; and

e Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan.

Payment (42 CFR 441.18(a)(4)):

Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

Case Records (42 CFR 441.18(a)(7)):

Providers maintain case records that document for all Individuals receiving case management as follows: (i)The -name of the individual; (ii) The dates of the case management services; (iii) The name of the provider agency (if relevant) and the person providing the case management service: (Iv) The nature, content, units of the case management services received and whether goals specified In the care plan have been achieved; (v) Whether the Individual has declined services In the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan.

Limitations:

Case management does not Include, and Federal Financial Participation (FFP) Is not available In expenditures for services defined in §440.169 when the case management activities are an integral and inseparable component of another covered Medicaid service (State Medicaid Manual (SMM) 4302.F).

Case management does not include, and Federal Financial Participation (FFP) is not

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[Children with Behavioral Health Disorders]

available In expenditures for, services defined in §440.169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c))

FFP only is available for case management services or targeted case management services If there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational , or other program except for case management that is Included in an individualized education program or Individualized family service plan consistent with §1903(c) of the Act. (§§1902(a)(25) and 1905(c))

[Specify any additional limitations.]

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[Members with Developmental Disabilities]

Target Group (42 Code of Federal Regulations 441.18(8)(i) and 441. 18(g)):

Adults with Developmental Disabilities must meet the following criteria:

An individual is eligible for case management services if he or she is age eighteen (18) or older and meets the eligibility requirements of Title 34B M.R.S.A.§3573, which defines developmental disabilities, or Title 34B M.R.S.A. §6002, which defines autism. A person who has reached his or her eighteenth (18") birthday and is under age twenty-one (21) may choose to receive case management services as an adult.

Children with Developmental Disabilities must meet the following criteria:

Acceptable standardized instruments means, for developmental disabilities, CHAT (ages 6 through 20), Vineland Adaptive Behavior Scales (up through age 20), Battelle Developmental Inventory (up through age 7), Bayley Scales of Infant and Toddler Development (age 1 month through 2 years), and Ages and Stages (and Ages and Stages Social Emotional scales) (up through age 5).

Children must meet the criteria listed below in subsection 1 OR 2 OR 3. In addition, children must meet the criteria listed in 4 to be eligible for TCM Services.

1. Meet the definition of developmental disabilities as defined in 22 M.R.S.A. §3573 or have an Axis II diagnosis of mental retardation as described in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders;

OR

Have an Axis I diagnosis of pervasive developmental disorder as described in the most recent Diagnostic and Statistical Manual of Mental Disorders;

OR

For children between birth and five (5) years of age:

a. Are determined by a professional approved by the Department as being at risk of developing a Pervasive Developmental Disorder due to known environmental or biological risks using DHHS adopted tools,

AND b. Have significant impairment or limitation in adaptive behavior or functioning according to criteria established by the Department (See Section 13.03-2(B)) and as determined by a qualified professional approved by the Department. 4. Level of Care Criteria for services assessed through the CHAT: a. Case management service is authorized for up to thirty (30) days from the date of the first billed encounter if the CHAT score is twenty (25) or less.

N

(vs)

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[Members with Developmental Disabilities]

b. Case management services may continue beyond thirty (30) days and up to ninety (90) days from the date of the first billed encounter if the CHAT score is at least between Twenty-six(26) and thirty-five (35).

c. Clinical information will be considered in addition to the CHAT scores above as the scores are not the sole criteria for eligibility and review.

d. Case management services may continue if the CHAT score is above 25. Service continuation will be dependent upon clinical information submitted.

4 Target group includes individuals transitioning to a community setting and are consistent with all federal guidelines. Case management services will be made available for up to 30 consecutive days of a covered stay in a medical institution. Reimbursement is made to community-based case managers and not the medical institution for this service. The target group does not include individuals between ages 22 and 64 who are served in Institution for Mental Disease or Individuals who are inmates of public institutions). (State Medicaid Director Letter (SMDL), July 25, 2000).

Areas of State In which services will be provided 1§1915(g)(1) of the Act): Entire State L] Only in the following geographic areas: [Specify areas]

Comparability of services (§§1902(a)(10)(B) and 1915(g)(1)) [_]Services are provided in accordance with §1902(a)(10)(B) of the Act. [XJServices are not comparable in amount duration and scope (§1915(g)(1)).

Definition of services (42 CFR 440.169): Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, In gaining access to needed medical, social, educational and other services. Targeted Case Management includes the following assistance:

“ Comprehensive assessment and periodic reassessment of Individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include e taking client history; e identifying the individual's needs and completing related documentation; and e gathering information from other sources such as family members, medical

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[Members with Developmental Disabilities]

providers, social workers, and educators (If necessary), to form a complete assessment of the eligible individual;

The comprehensive assessment must be completed within the first thirty (30) days of

Initiation of services and reassessment must minimally occur on an annual basis (or as a

change in the member's needs occur).

** Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that

e specifies the goals and actions to address the medical, social, educational, and other services needed by the individual;

e includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual's authorized health care decision maker) and others to develop those goals; and

e identifies a course of action to respond to the assessed needs of the eligible individual;

“+ Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including e activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address Identified needs and achieve goals specified in the care plan; and

“* Monitoring and follow-up activities are consistent with federal regulations and include: e activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible Individual's needs, and which may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary. Plans must be monitored at least every 90 days, or as the member's needs change and any change in the plan must be documented in the member's file. Monitoring will be conducted to determine whether the following conditions are met: © services are being furnished in accordance with the Individual's care plan; © services in the care plan are adequate; and o changes in the needs or status of the Individual are reflected in the care plan. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.

[x]Case management includes contacts with non-eligible individuals that are directly related to identifying the eligible individual's needs and care, for the purposes of helping the eligible Individual access services; Identifying needs and supports to assist the

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TARGETED CASE MANAGEMENT SERVICES ~~ = = = ~

[Members with Developmental Disabilities]

eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual's needs. (42 CFR 440.169(e))

Qualifications of providers (42 CFR 441.18(a)(8)(v) and CFR 441.18(b)):

Provider qualifications are as follows:

Staff Qualifications

Comprehensive Case Manager Qualifications a. Staff must have a minimum of a:

1. Bachelor's Degree from an accredited four (4) year institution of higher learning with a specialization in psychology, mental health and human services, behavioral health, behavioral sciences, social work, human development, special education, counseling, rehabilitation, sociology, nursing or closely related field,'

OR 2. Graduate of an accredited graduate school with a Master's Degree in social work, education, psychology, counseling, nursing or closely related field, OR 3. Bachelor's Degree from an accredited four (4) year institution of higher learning in an unrelated field and at least one (I) year of full-time equivalent relevant human services experience, OR 4. Staff who were employed at the time this rule goes into effect (8/1/2009) as a case manager providing services under the former subsections will be considered qualified.

Freedom of choice (42 CFR 441.18(a)(1)): The State assures that the provision of case management services will not restrict an Individual's free choice of providers In violation of section 1902(a)(23) of the Act. 1. Eligible Individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan. 2. Eligible Individuals will have free choice of any qualified Medicaid providers of other medical care under the plan.

Freedom of Choice Exception (§1915(g)(1) and 42 CFR 441.18(b)):

[_|Target group consists of eligible Individuals with developmental disabilities or

with chronic mental illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental illness receive needed services: [Identify any limitations to be Imposed on the providers and specify how these limitations

enable providers to ensure that individuals within the target groups receive

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Page 4e State Plan Title XIX of the Social Security Act wnt ciAl State/Territory: Maine coe ye

TARGETED CASE MANAGEMENT SERVICES

[Members with Developmental Disabilities]

needed services.]

Access to Services 42 CFR 441.18(a)(2). 42 CFR 441.18(a)(3). 42 CFR 441.18(a)(6): The State assures the following: e Case management (including targeted case management) services will not be used to restrict an individual's access to other services under the plan.

e Individuals will not be compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management)services; and

e Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan.

Payment (42 CFR 441.18(a)(4)):

Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

Case Records (42 CFR 441.(8)(a)(7)):

Providers maintain case records that document for all individuals receiving case management as follows: (I)The name of the Individual; (ii) The dates of the case management services; (Ill) The name of the provider agency (if relevant) and the person providing the case management service: (iv) The nature, content, units of the case management services received and whether goals specified In the care plan have been achieved; (v) Whether the Individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan.

Limitations:

Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440.169 when the case management activities are an Integral and Inseparable component of another covered Medicaid service (State Medicaid Manual (SMM) 4302.F).

Case management does not include, and Federal Financial Participation (FFP) Is not available in expenditures for, services defined In §440.169 when the case management activities constitute the direct delivery of underlying medical, educational. social, or other services to which an eligible Individual has been referred, Including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption

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State/Territory: Maine AGRTICL A L TARGETED CASE MANAGEMENT SERVICES (= = — =

[Members with Developmental Disabilities]

placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c))

FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that Is Included In an Individualized education program or individualized family service plan consistent with § 1903( c) of the Act. (§§ 1902(a)(25) and 1905(c)) [Specify any additional limitations.]

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[Members in Protective Services of DHHS]

Target Group (42 Code of Federal Regulations 441.18(8)(i) and 441.18(9))

Adults in Protective Custody must meet the specific eligibility requirements as follows:

Has attained the age of 18 years or is a legally emancipated minor; and a request or referral or nomination of guardianship or conservatorship has been submitted to the Office of Elder Services.

Children in Protective Custody must meet the specific eligibility criteria:

A child is under the age of eighteen (18) and is abused or neglected, or is suspected to be at risk of abuse or neglect; AND either a request or referral for investigation of suspected child abuse or neglect is submitted to the Office of Child and Family Services; OR

A child or young adult under age twenty-one (21) if the individual is either in the custody of the Department of Health and Human Services or of an agency in another State pursuant to a court order, or is in voluntary care of the Department or an agency in

state pursuant to a written agreement or is a family receiving post-adoption services or services provided within a Private Non-Medical Institution, as defined in Section 97, Private Non-Medical Institutions, of the MaineCare Benefits Manual.

[X]Target group Includes individuals transitioning to a community setting and are consistent with all federal guidelines. Case-management services will be made available for up to 30 days consecutive days of a covered stay in a medical institution. Reimbursement is made to community-based case managers and not the medical institution for this service. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public Institutions). (State Medicaid Directors Letter (SMDL), July 25, 2000)

Coverage and reimbursement of case management services for the protective services target group will cease on November 1, 2011.

Areas of State in which services will be provided (§1915)(g)(1) of the Act): x]Entire State [_JOnly in the following geographic areas: [Specify areas]

Comparability of services 1902(a)(10)(B) and 1915(g)(1)) [_]Services are provided in accordance with §1902(a)(10)(B) of the Act. [x]Services are not comparable in amount duration and scope (§1915(g)(1)).

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Supplement | to Attachment 3.1-A Page 5b

State Plan Title XIX of the Social Security Act State/Territory: Maine ayy TARGETED CASE MANAGEMENT SERVICES ~

[Members in Protective Services of DHHS]

Definition of services 42 CFR 440.169): Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, In gaining access to needed medical, social, educational and: other services. Targeted Case Management includes the following assistance:

«* Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities Include e taking client history;

e identifying the Individual's needs and completing related documentation; and -

e gathering Information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual;

The comprehensive assessment must be completed within the first thirty (30) days of

initiation of services and reassessment must minimally occur on an annual basis (or as

a change in the member's needs occur).

“* Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that

e specifies the goals and actions to address the medical, social, educational, and other services needed by the individual;

e includes activities such as ensuring the active participation of the eligible individual, and working with the Individual (or the Individual's authorized health care decision maker) and others to develop those goals; and

e identifies a course of action to respond to the assessed needs of the eligible individual;

“* Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including e activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and ** Monitoring and follow-up activities are consistent with federal regulations and include: activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual's needs, and which may be with the Individual, family members, service providers, or other entities or Individuals and conducted as frequently as necessary. Plans must be monitored at least every 90 days, or as the member's needs change and any

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Supplement | to Attachment 3.1-A

Page Sc State Plan Title XIX of the Social Security Act A State/Territory: Maine OFEt C TAL

TARGETED CASE MANAGEMENT SERVICES “~~

[Members in Protective services of DHHS]

change in the plan must be documented in the member's file.

Monitoring will be conducted to determine whether the following conditions

are met: © services are being furnished in accordance with the individual’s care plan; © services in the care plan are adequate; and o changes in the needs or status of the individual are reflected in the care plan. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers

Case management includes contacts with non-eligible individuals that are directly related to Identifying the eligible Individual's needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible Individual's needs.

(42 CFR 440.169(e))

Targeted Case Management Services for Members involved with protective/social welfare services are provided following a determination of the medical necessity for the services. The State Medicaid Agency determines the medical necessity for these services. Targeted Case Management services are provided after a determination that they are necessary to prevent, alleviate, prevent the worsening of or correct conditions that endanger life, cause suffering or pain, result in illness, Interfere with a person's capacity for normal activity.

Qualifications of providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)) Provider qualifications are as follows:

Staff Qualifications

Comprehensive Case Manager Qualifications a. Staff must have a minimum of a:

1. Bachelor's Degree from an accredited four (4) year institution of higher learning with a specialization in psychology, mental health and human services, behavioral health, behavioral sciences, social work, human development, special education, counseling, rehabilitation, sociology, nursing or closely related field,'

OR 2. Graduate of an accredited graduate school with a Master's Degree in social work, education, psychology, counseling, nursing or closely related field, OR Bachelor's Degree from an accredited four (4) year institution of higher learning in an unrelated field and at least one (I) year of full-time equivalent relevant human services experience,

wo

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Supplement | to Attachment 3.1-A Page 5d State Plan Title XIX of the Social Security Act State/Territory: Maine A TARGETED CASE MANAGEMENT SERVICES TAL

[Members in Protective services of DHHS]

OR

4. Staff who were employed at the time this rule goes into effect (8/1/2009) as a case manager providing services under the former subsections will be considered qualified.

Freedom of choice (42 CFR 441.18(a)(1)): The State assures that the provision of case management services will not restrict a individual's free choice of providers In violation of section 1902(a)(23) of the Act. 1. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area Identified in this plan. 2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan.

Freedom of Choice Exception (§1915)(g)(1) and 42 CFR 441.18(b)):

[_|Target group consists of eligible Individuals with developmental disabilities or

with chronic mental illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental illness receive needed services: [Identify any limitations to be Imposed on the providers and specify how these limitations

enable providers to ensure that individuals within the target groups receive

needed services.]

Access to Services (42 CFR 441.18(a)(2), 42 CFR 441.18(a)(3), 42 CFR 441.18(a)(6): The State assures the following:

e Case management (including targeted case management) services will not be used to restrict an individual's access to other services under the plan.

e Individuals will not be compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management) services; and

e Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan.

Payment (42 CFR 441.18(a)(4)):

Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

Case Records (42 CFR 441.18(a)(7)): Providers maintain case records that document for all individuals receiving case management as follows: (i)The name of the Individual; (ii) The dates of the case

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Supplement | to Attachment 3.1-A Page 5e State Plan Title XIX of the Social Security Act State/Territory: Maine OPT CT AT Gi

TARGETED CASE MANAGEMENT SERVICES = = ~ —

[Members in Protective Services of DHHS]

management services; (iii)The name of the provider agency (if relevant) and the person providing the case management service; (iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; (v) Whether the Individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan.

Limitations:

Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440.169 when the case management activities are an Integral and inseparable component of another covered Medicaid service (State Medicaid Manual (SMM) 4302.F).

Case management does not include, and Federal Financial Participation (FFP) is not available In-expenditures for, services defined in §440.169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers: home investigations; providing transportation; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c))

FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that is included in an Individualized education program or individualized family service plan consistent with §1903(c) of the Act. (§§1902(a)(25) and 1905(c))

[Specify any additional limitations.]

Coverage and reimbursement of case management services for the protective services target group will cease on November 1, 2011.

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Supplement | to Attachment 3.1-A Page 6a State Plan Title XIX of the Social Security Act State/Territory: Maine AGaTICT AL TARGETED CASE MANAGEMENT SERVICES *- > ~~ —

[Adults with Substance Abuse Disorders]

Target Group (42 Code of Federal Regulations 441.18(8)(i) and 441.18(9)):

Adults with Substance Abuse Disorders must meet the specific eligibility requirements as follows:

1. An adult who has an Axis I diagnosis(es) of substance abuse disorder(s) described in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) AND

2. Who is currently seeking substance abuse treatment services by a DHHS approved substance abuse treatment provider; AND

3. Who is pregnant, who is living with his or her minor children, and/or who is an intravenous drug user, AND

4. Who is enrolled in a substance abuse program which receives funding by the Substance Abuse Prevention Treatment Block Grant as provided by 42 U.S.C. section 300x-22(b).

xX Target group includes individuals transitioning to a community setting and are consistent with all federal guidelines. Reimbursement Is made to community-based case managers and not to the medical institution for this service. Case-management services will be made available for up to thirty (30) consecutive days of a covered stay ina medical institution. The target group does not include Individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions). (State Medicaid Directors Letter (SMDL), July 25, 2000).

Areas of State in which services will be provided (§1915(g)(1) of the Act): XxX] Entire State LJ Only in the following geographic areas: [Specify areas]

Comparability of services ($§1902(a)(10)(B) and 1915(g)(1)) im Services are provided in accordance with §1902(a)(10)(B) of the Act. Xx] Services are not comparable in amount duration and scope (§1915(g)(1)).

Definition of services (42 CFR 440.169): Targeted case management services are defined as services furnished to assist Individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services. Targeted Case Management includes the following assistance:

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Supplement | to Attachment 3.1-A Page 6b State Plan Title XIX of the Social Security Act ; State/Territory: Maine ADOT SG FAL TARGETED CASE MANAGEMENT SERVICES -

[Adults with Substance Abuse Disorder]

«* Comprehensive assessment and periodic reassessment of Individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include

e taking client history;

e identifying the individual’s needs and completing related documentation; and

e gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual:

The comprehensive assessment must be completed within the first thirty (30) days of Initiation of services and reassessment must minimally occur on an annual basis (or as a change in the member's needs occur).

** Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that

e specifies the goals and actions to address the medical, social, educational, and other services needed by the Individual;

e Includes activities such as ensuring the active participation of the eligible individual, and working with the Individual (or the individual's authorized health care decision maker) and others to develop those goals; and

e identifies a course of action to respond to the assessed needs of the eligible individual;

** Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including

e activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and

«* Monitoring and follow-up activities are consistent with federal regulations and include:

© activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible Individual's needs, and which may be with the Individual, family members, service providers, or other entitles or individuals and conducted as frequently as necessary. Plans must be monitored at least every 90 days, or as the member's needs change and any change in the plan must be documented in the member's file. Monitoring will be conducted to determine whether the following conditions are met:

9 services are being furnished In accordance with the individual's care plan;

© services In the care plan are adequate; and

o changes in the needs or status of the Individual are reflected In the care

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Supplement | to Attachment 3.1-A Page 6c

State Plan Title XIX of the Social Security Act ro State/Territory: Maine LO ae ere

TARGETED CASE MANAGEMENT SERVICES

[Adults with Substance Abuse Disorders]

plan.

Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.

xX Case management includes contacts with non-eligible Individuals that are directly related to identifying the eligible individual's needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible Individual's needs.

(42 CFR 440.169(e))

Qualifications of providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)): Provider qualifications are as follows:

Staff Qualifications Comprehensive Case Manager Qualifications a. Staff must have a minimum of a:

1. Bachelor's Degree from an accredited four (4) year institution of higher learning with a specialization in psychology, mental health and human services, behavioral health, behavioral sciences, social work, human development, special education, counseling, rehabilitation, sociology, nursing or closely related field,

OR

2. Graduate of an accredited graduate school with a Master's Degree in social work, education, psychology, counseling, nursing or closely related field, OR

3. Bachelor's Degree from an accredited four(4) year institution of higher learning in an unrelated field and at least one (1) year of full-time equivalent relevant human services experience,

OR

4. Staff who were employed at the time this rule goes into effect (8/1/2009) as a case manager providing services under the former subsections will be considered qualified.

Freedom of choice (42 CFR 441.18(a)(1)): The State assures that the provision of case management services will not restrict an individual's free choice of providers In violation of section 1902(a)(23) of the Act. 1. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan. 2. Eligible Individuals will have free choice of any qualified Medicaid providers of other medical care under the plan.

Freedom of Choice Exception (§1915(g)(1) and 42 CFR 441.18(b)):

TN 13-038 Approval Date: 03/11/2014 Effective Date 12/20/13 Supersedes TN:09-01 1a

zal

Supplement | to Attachment 3.1-A Page 6d State Plan Title XIX of the Social Security Act _ i awe State/Territory: Maine my EC LAL TARGETED CASE MANAGEMENT SERVICES ~

[Adult with Substance Abuse Disorders]

im Target group consists of eligible Individuals with developmental disabilities or with chronic mental illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental

disabilities or with chronic mental illness receive needed services: [Identify any limitations to be imposed on the providers and specify how these limitations enable providers to ensure that individuals within the target groups receive needed services.]

Access to Services (42 CFR 441.18(a)(2), 42 CFR 441.18(a)(3). 42 CFR 441.18(a)(6): The State assures the following:

e Case management (including targeted case management) services will not be used to restrict an individual's access to other services under the plan.

e Individuals will not tie compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management) services; and

e Providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan.

Payment (42 CFR 441.18(a)(4)):

Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

Case Records (42 CFR 441.18(a)(7)):

Providers maintain case records that document for all individuals receiving case management as follows: (i) The name of the individual; (ii) The dates of the case management services; (iii) The name of the provider agency (if relevant) and the person providing the case management service: (iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; (v) Whether the Individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A time line for reevaluation of the plan.

Limitations:

Case management does not Include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined In §440.169 when the case management activities are an integral and Inseparable component of another covered Medicaid service (State Medicaid Manual (SMM) 4302.F).

Case management does not include, and Federal Financial Participation (FFP) is not

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Supplement | to Attachment 3.1-A

Page 6e

State Plan Title XIX of the Social Security Act

State/Territory: Maine Cr

7 tk

TARGETED CASE MANAGEMENT SERVICES

eran On A

[Adults with Substance Abuse Disorders]

available In expenditures for, services defined in §440.169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other

services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or Interviewing potential foster care parents; serving legal papers;

home investigations; providing transportation; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c))

FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that Is Included In an Individualized education program or Individualized family service plan consistent with §1903(c) of the Act. (§§1902(a)(25) and 1905(c)) [Specify any additional limitations.]

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Supplement | to Attachment 3.1-A Page 6f State Plan Title XIX of the Social Security Act State/Territory: Maine ATatey AL TARGETED CASE MANAGEMENT SERVICES_ -

F: The State assures that the provision of case management services will not restrict an individual’s free choice of providers in violation of section 1902(A)(23) of the Act.

1. Eligible recipients will have free choice of providers of case management services.

2. Eligible recipients will have free choice of the providers of other medical care under the plan.

G. Payments for case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for the same purpose.

TN 13-038 Approval Date: 03/11/2014 Effective Date 12/20/13 Supersedes TN:09-011a

Table of Contents

State/Territory Name: Maine

State Plan Amendment (SPA) #:14-0005-MM7

This file contains the following documents in the order listed:

1) Approval Letter

2) Companion Letter

3) CMS 179 Form/Summary Form

4) Approved SPA Pages

5) Presumptive Eligibility Training

6) Presumptive Eligibility Application

7) Hospital Presumptive Eligibility Denial Notice

8) Hospital Presumptive Eligibility Approval Card

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

January 13, 2015

Mary Mayhew, Commissioner Department of Health and Human Services 11 State House Station

Augusta, Maine 04333-0011

RE: Maine ME 14-0005MM7 Dear Commissioner Mayhew:

We are pleased to enclose a copy of approved Maine State Plan Amendment (SPA) No. 14-0005MM7 submitted to CMS on March 30, 2014. This SPA was submitted to revise your approved Title XIX State plan to describe the state's policies related to hospital presumptive eligibility. This SPA has been approved effective January 1, 2014.

Enclosed are copies of the following State plan pages and attachments to be incorporated within a separate section at the end of your approved State plan.

¢ S21- Presumptive Eligibility by Hospitals, pages 1-3:

¢ Hospital Presumptive Eligibility Training Materials, pages 1-41; ¢ Hospital Presumptive Eligibility Current Application, pages 1-2; ¢ Hospital Presumptive Eligibility Card. pages 1-2: and

* Hospital Presumptive Eligibility Denial Notice, pages 1-2.

A companion letter is also attached to this SPA approval package requiring a corrective action plan.

If you have any questions regarding this SPA, please contact Aimee Campbell-O’ Connor, Maine State Lead, at 617/565-1642, or at Aimee.Campbell-O’ Connor/@cms.hhs.gov.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

cc: Stefanie Nadeau, Director, Office of Maine Care Services

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

January 13, 2015

Mary Mayhew, Commissioner Department of Health and Human Services 11 State House Station

Augusta, Maine 04333-0011

RE: Maine ME 14-0005MM7 Dear Commissioner Mayhew:

This letter is being sent as a companion to our approval of Maine State Plan Amendment (SPA) ME-14-0005MMT7, which proposes to implement presumptive eligibility conducted by hospitals in the Medicaid state plan in accordance with the Affordable Care Act. This amendment was submitted on March 30, 2014, with an effective date of January 1, 2014.

Section 1902(a) of the Social Security Act (the Act) requires that states have a state plan for medical assistance that meets certain Federal requirements that set out a framework for the

state program. Implementing regulations at 42 CFR 430.10 require that the state plan be a comprehensive written statement describing the nature and scope of the state’s Medicaid Program and that it contain all information necessary for the Centers for Medicare & Medicaid Services (CMS) to determine whether the plan can be approved to serve as the basis for Federal financial participation (FFP) in the state program. While the SPA is approvable, CMS’ analysis determined that additional changes related to the state’s implementation of the hospital presumptive eligibility provision are needed in the Maine Medicaid state plan.

As set forth in Section 1902(a)(47)(B) of the Social Security Act, states must provide a program for hospitals that choose to provide hospital presumptive eligibility determinations, effective January 1, 2014, as codified in the Section 2202 of the Affordable Care Act. Maine has provided sufficient SPA pages and supporting materials in the ME-14-0005MM7 submission to show that it has policies in place and can begin to train hospitals as qualified entities, allowing CMS to approve this SPA. CMS acknowledges that Maine needs time to promulgate state rules before fully implementing its hospital presumptive eligible program, so we are giving the state time to come into compliance with its approved state plan, which has an effective date of January 1, 2014. The state has indicated that it expects to implement its hospital presumptive eligibility program within five to six months from the date of this SPA’s approval, i.e., May or June 2015.

/s/

/s/

Medicaid Eligibility OFFICIAL

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

Presumptive Eligibility by Hospitals $21

42 CFR 435.1110

One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision.

@ Yes (No

The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: {m@) A qualified hospital is a hospital that: Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration. notifies the Medicaid agency of [WJ its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance [B] with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. Assists individuals in completing and submitting the full application and understanding any documentation requirements. @Yes (No [i] The eligibility groups or populations for which hospitals determine eligibility presumptively are: [@] Pregnant Women {m) Infants and Children under Age 19 {@) Parents and Other Caretaker Relatives [@] Adult Group. if covered by the state [M] Individuals above 133% FPL under Age 65, if covered by the state [@] Individuals Eligible for Family Planning Services, if covered by the state [] Former Foster Care Children (M] Certain Individuals Needing Treatment for Breast or Cervical Cancer. if covered by the state [J Other Family/Adult groups: (J Eligibility groups for individuals age 65 and over [J Eligibility groups for individuals who are blind (J Eligibility groups for individuals with disabilities (J Other Medicaid state plan eligibility groups (J Demonstration populations covered under section 1115

The state establishes standards for qualified hospitals making presumptive eligibility determinations.

TN 14-0005-MM7 S21 Approval Date: 1/13/2015 Maine Page 1 of 3 Effective Date: 1/1/2014

cms Medicaid Eligibility OFFICIAL

CONTE FEM AMETAE 8 BOCA NET

@Yes ©No

Select one or both:

x The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period.

Ifa hospital fails on three occasions to submit a regular application after making a PE Description of standards: |determination and/or makes a PE determination for someone who is ultimately found ineligible for coverage, the hospital will lose the ability to perform PE determinations.

x The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the

submission of an application before the end of the presumptive eligibility period.

Ifa hospital fails on three occasions to submit a regular application after making a PE Description of standards: |determination and/or makes a PE determination for someone who is ultimately found ineligible for coverage, the hospital will lose the ability to perform PE determinations.

{@] The presumptive period begins on the date the determination is made. [i] The end date of the presumptive period is the earlier of

The date the eligibility determination for regular Medicaid is made. if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made: or

The last day of the month following the month in which the determination of presumptive eligibility is made. if no application for Medicaid is filed by that date.

{@) Periods of presumptive eligibility are limited as follows: C No more than one period within a calendar year. C No more than one period within two calendar years.

No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

@ Other reasonable limitation:

Name of limitation Description I

Periods of eligibility will be limited to no more than one period within a 24-month period, starting with

the effective date of the initial presumptive x eligibility period.

+e | 24 Month Period Limitation

The state requires that a written application be signed by the applicant, parent or representative, as appropriate. @ Yes C No C The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

5 The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included.

TN 14-0005-MM7 $21 Approval Date: 1/13/2015 Maine Page 2 of 3 Effective Date: 1/1/2014

An attachment is submitted.

(@) The presumptive eligibility determination is based on the following factors: The individual’s categorical or non-financial eligibility for the group for which the individual's presumptive eligibility is [H] being determined (e.g.. based on age, pregnancy status, status as a parenv/caretaker relative, disability. or other requirements

specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group)

i Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined. if'an income standard is applicable for this group.

IX] State residency Citizenship, status as a national, or satisfactory immigration status

The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included.

An attachment is submitted.

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

TN 14-0005-MM7 S21 Approval Date: 1/13/2015 Maine Page 3 of 3 Effective Date: 1/1/2014

OFFICIAL

Hospital Presumptive Eligibility

Understanding How to Make Presumptive Eligibility Determinations for Medicaid Coverage

Maine Department of Health and Human Services

Office for Family Independence

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OFFICIAL

What is presumptive eligibility?

Determining that an individual is eligible for Medicaid coverage based on a presumption of facts related to eligibility requirements such as income, citizenship, etc. — requirements that normally must be verified before eligibility is granted.

Approval Date: 1/13/2015

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Maine Page 2 of 41

OFFICIAL

Who can make presumptive eligibility determinations?

© A limited number of providers (e.g., Family Planning Clinics and Federally Qualified Health Centers) have been making presumptive eligibility (PE) determinations for pregnant women for several years.

Effective TBD, any hospital in the State of Maine that asks to do so will be allowed to make PE determinations for a broader population, provided the hospital agrees to certain conditions.

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OFFICIAL

Who is eligible for a presumptive

eligibility determination?

e Family Planning Clinics and Federally Qualified Health Centers will still only make PE determinations for pregnant women.

© Qualified hospitals will be able to make PE determinations for:

TN 14-0005-MM7 Maine

oO

°o

Pregnant women;

Parents and caretaker relatives of children under the age of 18;

Children under the age of 21;

Individuals under age 26 who were in foster care in Maine at age 18; and

Women who are in treatment for breast and cervical cancer.

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OFFICIAL

What are the steps for making a presumptive eligibility determination?

Step |

Ask the individual to complete a PE application (HPE-App).

Note:A hospital cannot ask the applicant for verification of any information included on the application

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OFFICIAL

What are the steps for making a presumptive eligibility determination? (continued)

Step 2

Determine if the applicant fits into a coverable group (e.g., parent/caretaker relative, child under 21, pregnant woman,

etc.).

This determination is based on information from the HPE application.

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OFFICIAL

What are the steps for making a presumptive eligibility determination? (continued)

Step 3 Confirm with the Department that:

e the applicant is not already enrolled in MaineCare and/or

e the applicant has not received a PE determination within the last 24-months

Confirmation will be made via telephone

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OFFICIAL

What are the steps for making a presumptive eligibility d eterm nati on ? (continued)

Step 4 Determine the applicant’s countable MAGI income and household size.

This determination is based on information from the HPE application.

Approval Date: 1/13/2015

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Main Page 8 of 41

OFFICIAL

What are the steps for making a presumptive eligibility determination? continued)

Step 4 (continued)

To determine the applicant’s countable MAGI income and household size, enter

applicable data from the HPE application into the MAGIC tool.

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Page 9 of 41 Effective Date: 1/1/2014

OFFICIAL

What are the steps for making a presumptive eligibility determination? (continued)

Step 5 The MAGIC tool will confirm the applicant's eligibility for HPE coverage.

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OFFICIAL

What are the steps for making a presumptive eligibility determination? (continued)

Special Rule for Former Foster Care Children

e If an individual is under age 26 and was in foster care in Maine at age 18, there is no income test

This special rule applies to the individual only — not his/her family members

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OFFICIAL

What is MAGI?

» Modified Adjusted Gross Income (MAGI)

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is a methodology based on federal tax rules for how income is counted and family size is determined for Medicaid eligibility. MAGI is NOT a number on a

tax return.

OFFICIAL

3 Step Process for Determining Eligibility

° Identify members of the individual's family who are considered part of his/her household and determine family size

:. Add the income of all the relevant members of the individual’s household.

_* Compare total household income to the federal poverty level for the individual’s family size. Note: income must not be calculated for individuals under age 26 who were formerly in foster care in Maine at age 18.

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OFFICIAL

Tax Filing Information

e When constructing a household for PE determinations, we need to know if the individual plans to file a federal tax return or expects to be claimed as a tax dependent for the year in which coverage is sought.

@ Individual’s household is constructed based on his plan to file — regardless of whether or not he ultimately files a return at the end of the year — or be claimed as a tax dependent.

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OFFICIAL

General Rules: Constructing a Household

e Construct a household for each individual listed on the application/renewal form who is applying for PE coverage (this is because eligibility is determined at the individual level).

° An individual’s household may or may not include everyone listed on the application form.

° Different households may exist within a single family, depending on each of the family members’ familial and tax relationships to each other.

e Example: An individual’s family size may include 3 persons, but that does not necessarily mean that

those 3 individuals will all have the same household size.

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OFFICIAL

Constructing a MAGI Household for EACH Applicant — Step A

A. Does the individual expect to file taxes?

|. Ifno—continue to Step B.

2. If yes — does the individual expect to be claimed as a tax dependent by anyone else?

a. If no—the household consists of the taxpayer, a spouse living with the taxpayer (or estranged spouses filing jointly), and all persons whom the taxpayer expects to claim as a tax dependent.

b. If yes — continue to Step B.

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OFFICIAL

Step B

~B. Does the individual expect to be claimed as a tax dependent?

|. If no —continue to Step C.

2. If yes — does the individual meet any of the following exceptions?

a. The individual expects to be claimed as a tax dependent of someone other than a spouse or a biological, adopted or step parent.

b. The individual is a child under age 19 living with both parents, but will only be claimed as a tax dependent by one.

c. The individual is a child under age 19, living with a custodial parent/caretaker relative, but expects to be claimed by a non- custodial parent.

If the individual does NOT meet any of these exceptions, the household

is the same as the household of the taxpayer claiming him/her as a tax

dependent. NOTE: If the individual is married, the household also includes the individual's spouse.

If the individual meets any of the exceptions listed above — continue to

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OFFICIAL

Step C

Cc. For individuals who neither expect to file a tax return nor expect to be claimed as a tax dependent, as well as tax dependents who meet one of the exceptions from Step B-2, the household consists of the individual and, if living with the individual — |. The individual’s spouse;

2. The individual’s natural, adopted and step children under the age of 19; and

3. In the case of individuals under the age of 19, the individual’s natural, adopted and step parents and natural, adoptive and step siblings also under the age of 19.

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OFFICIAL

Household Example

Joseph Tax Filer

Tessa Household Description Tax Filer Joseph (32 yrs. old) is applying for PE coverage for himself, his girlfriend, Tessa (28 yrs. old), and their bs J mutual child, Avery (7 yrs. : old). They all live together. Joseph and Tess are both required to file taxes and

Son Son

will be filing separately. ( iy Avery is a tax dependent of fe Joseph. vary

Tax Dependent of, Joseph proval Date: 1/13/2015

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OFFICIAL

Determine Joseph’s Household

|. Does Joseph expect to file taxes? Yas

2. If yes — Does Joseph expect to be claimed as a tax dependent by anyone else? \\o

a. Joseph’s household includes Joseph (the taxpayer) and his tax dependent, Avery.

Medea ere

Eligibility — ‘Cateser Household For ee Size Joseph Parent Count cet Count 2 Tessa

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Maine Page 20 of 41 Effective Date: 1/1/2014

OFFICIAL

Determine Tessa’s Household

Does Tessa expect to file taxes? Yes

If yes — Does Tessa expect to be claimed as a tax dependent by anyone else? No

a. Tessa is not married and is not claiming any tax dependents. Her household size is one.

Joseph Parent Counted Coured Tessa Parent Not Counted Counted

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Counted 2

Not Counted

Approval Date: 1/13/2015 Effective Date: 1/1/2014

OFFICIAL

Determine Avery’s Household

A. Does Avery expect to file taxes? No

B. Does Avery expect to be claimed as a tax dependent? Yes

2. Does he meet any of the following exceptions? a. Does he expect to be claimed as a tax dependent of someone other than a spouse or parent? No

b. Is he under age 19 living with both parents, but will only be claimed as a dependent by one? Yes

Approval Date: 1/13/2015

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Main: Page 22 of 41

OFFICIAL

Avery’s Household (continues)

c. Avery meets one of the exceptions from B-2. His household consists of himself and his parents.

Medicaid pee do. ee MAGI

Eligibility | acne a ‘| Household |

For Size Joseph Parent Counted CN eted Counted 2 ‘Tosca. Not Not

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Maine Page 23 of 41 Effective Date: 1/1/2014

OFFICIAL

MAGI Income

e Countable income is taxable income minus certain expenses.

e Expenses include: ° Alimony e Student Loan Interest ° Pre-tax deductions (403b, 401K, health savings accounts) All disregards will be replaced by a fixed amount determined by household size.

@ Income is not calculate for individuals under age 26 who were in foster care in Maine at the age of 18.

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OFFICIAL

Whose Income Is Counted?

_ © Each individual’s household must be constructed before determining whose income counts.

° It is possible for someone’s income to be counted in one MAGI household but not another.

The basic rule for income is this: MAGI income for all individual who are counted

ina MAGI household should be counted. There are 2 exceptions to the basic rule.

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OFFICIAL

Determining MAGI Income for Each Household — Second Exception

Is the individual the tax dependent of someone in this MAGI household who is not the individual’s spouse or parent?

|. If yes — Is the individual expected to be required to file a tax return?

a. If yes, the individual’s income must be included in this MAGI household’s total MAGI income.

b. If no, the individual’s income should NOT be included in this MAGI household’s total MAGI income.

2. If no, the individual’s income must be included in this MAGI household’s total MAGI income.

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OFFICIAL

Income Example

Joseph ° ye Tessa Tax Filer Household Description Tax Filer

» Joseph: $1,200/mo. earned » Tessa: $450/mo. earned

» Avery: No income | a

¢ ‘ * ¥ Joseph and Tess are both . 4 required to file taxes and will be filing separately. Son Son Avery is a tax dependent of i &) Joseph. by 2 7 Avery Tax Dependent of Jose h S21-Hospital Presumptive Eligibility Training proval Date: 1/13/2015 Effective Date: 1/1/2014

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OFFICIAL

Whose income counts in Joseph’s

household? ° The household consists of Joseph and Avery. Only Joseph has income.

e You must determine if each individual in the household meets any exceptions to the general rule.

° Exception |: Are Joseph’s parents in his MAGI household? No

e Exception 2: Is Joseph the tax dependent of someone in his household who is not his spouse or parent? No

e Joseph doesn’t meet any exceptions so his income counts.

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OFFICIAL

Whose income counts in Tessa’s

household?

Tessa is the only member in her MAGI household so she will not meet any exceptions.

e Her income counts in her household.

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OFFICIAL

Whose income counts in Avery’s

household?

e The household consists of Joseph, Tessa and Avery. Joseph and Tessa have income.

e You must determine if each individual in the household meets any exceptions to the general rule.

° Exception |: Are Joseph’s/Tessa’s parents in Avery’s MAGI household?

e Exception 2: Is Joseph/Tessa the tax dependent of someone in Avery’s MAGI household who is not his/her spouse or parent?

Joseph and Tessa don’t meet any exceptions so their income counts.

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Maine

OFFICIAL

Determine Financial Eligibility

Avery's Eligibility

e Countable income © Joseph’s earnings: $1200 ° Tessa’s earnings: $450 ° Total countable: $1650

e MAGI Standard Disregard for HH of 3: $82 e $1650 — 82 = $1568

e Compare countable income to appropriate FPL for HH size. $1568 < $2556 (157% FPL)

pital Presumptive Eligibility Training age 32 of 41

OFFICIAL

An applicant is found eligible for PE coverage, what happens next?

Once a hospital has determined an applicant to be eligible for PE coverage, the hospital must — at the time of determination:

e Provide each approved individual with a completed MaineCare Hospital PE Card — this will serve as written notification of the individual's eligibility for PE coverage;

e Assist each individual determined presumptively eligible with completing and submitting a full MaineCare application — the individual may use a paper application or apply online at www.maine.gov/mymaineconnection.

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OFFICIAL

An applicant is found eligible for PE coverage, what happens next? (continued)

Once a hospital has determined an applicant to be eligible for PE coverage, the hospital must — at the time of determination:

° Inform each approved individual that PE coverage will end on the earlier of:

© The day on which an eligibility decision has been made on the applicant’s full MaineCare application (if submitted); or

° The last day of the month following the month in which a presumptive eligibility decision was made (if a full application was not submitted).

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OFFICIAL

An applicant is found eligible for PE coverage, what happens next? (continued)

Once a hospital has determined an applicant to be eligible for PE coverage, the hospital must — at the time of determination:

Provide a copy of the completed Hospital PE Card to the Office for Family Independence (OFI) for each PE determination within 5 working days from when the determination was made. Copies can be submitted via the postal service, fax or email.

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OFFICIAL

An applicant is found ineligible for PE coverage, what happens next?

If a hospital has determined an applicant to be ineligible for PE coverage, the hospital must:

e Inform the applicant of the reason for the denial of coverage — this must be shared in writing and orally, if appropriate; and

° Inform the applicant that he/she may still file a full MaineCare application.

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OFFICIAL

Payment for Medical Services

e The Department will not hold hospitals financially responsible if an individual is found ineligible for Medicaid based on a full eligibility determination,

BUT

e The Department will not pay claims for individuals determined presumptively eligible if the hospital does not notify OFI of the PE determination within 5 working days of the determination.

OFFICIAL

PE Performance Standards for

Hospitals

© If a hospital:

° Fails to notify OFI of a PE determination within 5 working days of the determination;

° Fails to submit a completed full MaineCare application on behalf of the individual before the end of the PE period; and/or

e Makes a PE determination for someone who is ultimately found to be ineligible for Medicaid coverage,

the hospital will receive a written warning from OFI that documents the reason for the warning.

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OFFICIAL

PE Performance Standards for

Hospitals (continued) © If a hospital for the second time:

° Fails to notify OFI of a PE determination within 5 working days of the determination;

° Fails to submit a completed full MaineCare application on behalf of the individual before the end of the PE period; and/or

o Makes a PE determination for someone who is ultimately found to be ineligible for Medicaid coverage,

the hospital will receive a written warning from OFI that documents the reason for the warning and require all applicable staff to participate in additional PE training provided by OFFI.

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OFFICIAL

PE Performance Standards for Hospitals (continued)

If a hospital for a third time:

TN 14-0005-MM7 Maine

° Fails to notify OFI of a PE determination within 5 working days of the determination;

° Fails to submit a completed full MaineCare application on behalf of an individual before the end of the PE period; and/or

o Makes a PE determination for someone who is ultimately found to be ineligible for Medicaid coverage,

the hospital will receive a written notification from OFI that it will no longer be allowed to make PE determinations.

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OFFICIAL

Questions?

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OFFICIAL PRESUMPTIVE ELIGIBILITY APPLICATION

Name of Applicant: Date of Birth: Social Security Number (optional): Phone Number: Address: YES NO 1. Do you have a current MaineCare card? If yes, stop here. Oo Oo 2. Are you a resident of the State of Maine? oO o 3. Are you a U.S. Citizen or a legal alien? Oo Oo 4. Are you: O Married O Divorced OSingle O Widowed O Separated 5. Household Member Information (if the Applicant or any other family member receives earned or

unearned income (including income from: employment, self-employment, tips, commissions, pensions, Social Security, child/spousal support, gifts, disability, VA or unemployment benefits, etc.), list the amount received under Gross Income Received, where the money came from under Source, and how often the money is received under Frequency).

Social Relationshi Source Name (Last, Applying | Security to the P Date of | Gross of Frequency First, Middle for Number Applicant Birth Income Income Initial) coverage? | (Optional) PP Received Self 6. Does anyone in the household pay alimony, pay interest on a student loan, or have any pre-tax

deductions from earnings? If so, who, what is the amount paid and how often is it paid/deducted?

Is anyone in the household who is applying for coverage pregnant? If so, who and how many babies is she expecting?

Is anyone in the household who is applying for coverage a former foster care child from the State of Maine who was enrolled in MaineCare at the time he/she “aged out” of foster care? If so, who?

By signing below, | swear that everything written above on this form is true as far as | know.

Applicant’s Signature: Date:

HPE-App 01-2014 TN 14-0005-MM7 $21-Hospital Presumptive Eligibility Application Approval Date: 1/13/2015 Maine Page 1 of 2 Effective Date: 1/1/2014

Presumptive eligibility determination for:

Coverage group (check one):

MAGI! Monthly Income

Less any applicable expenses

Less applicable standard disregard

Total Countable MAGI Monthly Income

For Provider Use Only

OFFICIAL

Parent/Caretaker Relative

Pregnant Woman

Woman in Treatment

Child Under Age 21

Former Foster Care Child (Note: There is no income test for

for Breast or Cervical Cancer

Maximum Income Levels as of January 1, 2014

this coverage group)

Family Size] Parent/ | Ages Birth to | Ages 1 to 18] Ages 19 & 20 | Pregnant | Woman with| 5% Standard Caretaker (inclusive) | (inclusive) Women _| Breast or Income Relative Cervical Disregard

Cancer

100% FPL| 191% FPL 157% FPL 156% FPL 209% FPL | 250% FPL

1 S$ 973 $1,829 $1,504 $1,494 $2,002 $2,432 $ 49

2 $1,311 | $2,469 $2,030 $2,017 $2,702 $3,278 S 66

3 $1,650 | $3,109 $2,556 $2,539 $3,402 $4,125 S 83

4 $1,988 | $3,749 $3,082 $3,062 $4,102 $4,970 $99

5 $2,326 | $4,389 $3,608 $3,585 $4,802 $5,815 $116

6 $2,665 | $5,029 $4,134 $4,107 $5,502 $6,663 $133

7 $3,003 _| $5,668 $4,659 $4,630 $6,203 _| $7,508 $150

8 $3,341 | $6,308 $5,185 $5,152 $6,903 $8,353 $167

Each

Additional | $ 339 S 640 S 526 $ 523 $ 701 $ 848 $17

Person

Is the applicant already enrolled in MaineCare? CL) Yes [No

Has the applicant been determined presumptively eligible once within the past 24-months? LJ Yes LJ No

Does the applicant meet all remaining Presumptive Eligibility Requirements?

Signature of Authorized Individual:

Date of Presumptive Eligibility Determination:

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Maine

OO Yes

OONo

$21-Hospita! Presumptive Eligibility Application Page 2 of 2

HPE-App 01-2014

Approval Date: 1/13/2015 Effective Date: 1/1/2014

Hospital Presumptive Eligibility for MaineCare Coverage Notice of Ineligibility Decision OFFICIAL

has determined that the following

(name of hospital making the determination)

individual, is not eligible for (name of person seeking presumptive eligibility)

presumptive eligibility coverage through MaineCare because of the following reason(s): (check all that apply) 1. Individual does not have coverage group.

2. Countable household income exceeds the maximum income level for the individual’s coverage group.

3. Individual does not meet the citizenship requirements for MaineCare coverage.

4. Individual has received presumptive eligibility coverage in Maine through a hospital within the past two years.

____ 5. Other (please specify the reason):

Although you are not eligible for presumptive eligibility coverage through MaineCare, you may obtain a full determination of eligibility by submitting a completed application for MaineCare coverage to the Maine Department of Health and Human Services’ Office for Family Independence. You can complete and submit this application online at

www.maine. gov/mymaineconnection: you can also call 1-855-797-4357 to learn of other ways you can submit an application.

Signature of Hospital Representative:

(Date)

HPE Denial R12-2014 TN 14-0005-MM7 $21- Hospital Presumptive Eligibility Denial Notice Approval Date: 1/13/2015 Maine Page 1 of 1 Effective Date: 1/1/2014

State of Maine Department of Health and Human Services

MaineCare Hospital Presumptive Eligibility Card OFFICIAL Please Print 1) Name:

(Last Name) (First Name) (Middle Initial) 2) Address:

(Street) (City/Town) (State) (Zip Code)

3) Date of Birth:

4) Eligibility: A. Starts: (Today’s Date)

B. Ends: (Last Day of Month following Start Month*)

* NOTE: If the eligibility period has expired, this client may still be eligible for MaineCare coverage. The regulations at 42 CFR 435.1101 to 1110 define a period of presumptive eligibility. Specifically, a period of presumptive eligibility means a period that begins on the date on which a qualified entity determines that an applicant is presumptively eligible and ends with the earlier of— (1) In the case of an applicant on whose behalf a Medicaid application has been filed, the day on which a decision is made on that application; or (2) In the case of an applicant on whose behalf a Medicaid application has not been filed, the last day of the month following the month in which the determination of presumptive eligibility was made. Please call the DHHS Regional Office to verify MaineCare eligibility.

5) Hospital Making Eligibility Determination:

(Name) (Address)

6) Signature of Hospital Representative:

(Date)

To Member: Always show this card to your health care provider. Services to be provided will be the same as those provided to the eligibility group for which you were determined presumptively eligible.

To Provider: Provide a copy of this form (via mail or fax) to the applicable DHHS Regional Office

HPE Card RO1-2014 TN 14-0005-MM7 $21-Hospital Presumptive Eligibility Approval Card Approval Date: 1/13/2015 Maine Page 1 of 1 Effective Date: 1/1/2014

Table of Contents

State/Territory Name: Maine

State Plan Amendment (SPA) #:15-025

This file contains the following documents in the order listed:

1) Approval Letter

2) CMS 179 Form

3) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

aan

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 14, 2016

Mary Mayhew, Commissioner Department of Health and Human Services 11 State House Station

Augusta, Maine 04333-0011

RE: Maine ME 15-025 Dear Commissioner Mayhew:

We are now ready to approve State Plan Amendment (SPA) No. ME 15-025; attached you will find an approved copy of the SPA. As requested, this SPA is effective July 1, 2016.

The purpose of this SPA is to amend the State’s approved Title XIX State Plan to clarify the state’s coverage of family planning and family planning related services to go along with

SPA 15-026 which added the Family Planning eligibility option to the State Plan. This SPA is estimated to have a Federal Fiscal year impact of $280,694 in 2016 and $1,122,776 in 2017.

If you have any questions regarding this SPA, please contact Aimee Campbell-O’Connor, Maine State Lead, at 617/565-1642, or at Aimee.Campbell-O’ Connor@cms.hhs.gov.

Sincerely, /s/ Richard R. McGreal

Associate Regional Administrator

cc: Stefanie Nadeau, Director, Office of Maine Care Services Sam Senft, Director, Policy, Children’s and Waiver Services

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL l. TRANSMlITAL NillvfBER: 15-025 2. STATE Maine FOR: HEALTH CARE FJNANCING ADMINISTRATION 3. PROGRAM 1DENTIFJCA TION: TITLE XTX OF TI-IE SOCIAL SECURITY ACT (MEDlCAID) TO: REGIONAL ADMJN1STRATOR Centers for Medicare and Medicaid Services Department of Health and Human Services 5. TYPE Of PLAN MATERIAL (Check One): 4. PROPOSED EFFECTfVE DA TE A̼l!itlXlro6< July 1, 2016 O NEW STATE PLAN O AMENDMENT TO BE CONSIDERED AS NEW PLAN 0 AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THJS IS AN AMENDMENT "Se orate Transmittal or eadi amendment 6. FEDERAL STATUTE/REGULA TTON CITAT[ON: 7. FEDERAL BUDGET IMPACT: l:902(a)(lO)(A)(ii)(XXI) a. FFY_2016 is a cost of̽ $280,694 b. FFY 2017 is a cost of $1, 122,776 8. PAGE NUMBER OF THE PLAN SECTION OR ATIACHivfENT: Attachment 3.1-A Page 1 a Attachment 3.1-A Page 2b Attachment 3.1-A Page 2c 10. SUBJECT OF AMENDMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): M̾̿̀).(́ Attachment 3.1A, page 1 Election of the family Planning Eligibility Option, coverage description l l. GOVERNOR'S REVIEW (Check One): O GOVERNOR'S OFFICE REPORTED NO COJvIMENT O COMMENTS OF GOVERNOR'S OFFICE ENCLOSED ONO REPLY RECEIVED WJTHfN 45 DAYS OF SUBMln'AL .:SIGNATifRE OF STAT.F. AGFNC'V OFFICIAL: Isl 0 OTHER, AS SPECIFIED: Director, Office of MaineCare Services 16. RETURN TO: 1 13. l . EDNAME: 1 · :vr ·· · · - -._,·----------------l Stefanie Nadeau ' Stef. 'Nadeau Director, MaineCare Services _:::_=::::;:i;:...;..:.:.===-------------------l #1 I State House Station, 14. T[T E: 242 State Street Director, Office ofMaineCare Servic.cs 15. DATE SUBMITTED: Augusta, Main_͂ 04333-0011 The state provided pen and ink authority to update this 179 to be consistent with the state's submission on 3/2/16. nc a 7/1/16

State/Territory: Maine Attachment 3.1-A Page la

State Plan Title XIX of the Social Security Act

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

Item 1. Inpatient Hospital Services

Inpatient Hospital Services are provided in accordance with 42 CFR 440.10. Prior authorization (PA) required for extension of hospital benefit days beyond 60 days. Intensive care and coronary care services do not require prior authorization.

OFFICIAL

TN No 15-025 Supersedes TN No. 84-11 Approval Date - 3/14/16 Effective Date: 7/01/2016

State/Territory: Maine Attachment 3.1-A

Page 2b State Plan Title XIX of the Social Security Act

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

Item 4a Nursing Facility Services

Private rooms and private duty nursing are not covered except when therapeutically necessary.

OFFICIAL

TN No: 15-025

Supersedes TN No. NEW Approval Date - 3/14/16 Effective Date: 7/01/2016

State/Territory: Maine Attachment 3.1-A Page 2c State Plan Title XIX of the Social Security Act

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED

Item 4c. Family Planning Services

OFFICIAL

Family planning services and supplies

1905(a)(4)(C)():

e Office visits for purposes of family planning, including patient history, contraceptive counseling, breast and pelvic exams, and laboratory tests;

e Pharmaceutical supplies and devices to prevent conception, including all methods of contraception approved by the Federal Food and Drug Administration.

e Over-the-counter contraceptives, including condoms, spermicides and sponges, if prescribed.

e Family planning education, counseling, follow-ups, and referrals;

e Limited laboratory examinations and tests for the purposes of family planning; and

e Male and female sterilization procedures and follow up tests provided in accordance with 42 CFR 441, Subpart F.

Family planning-related services

1905(a)(4)(C)(Gii)

¢ Treatment of major complications related to family planning services and family planning- related procedures;

e PAP screens and treatment for pre-cancerous conditions which commonly originate froma Sexually Transmitted Infection (STI);

e Vaccines to prevent STIs; and

e Diagnostic procedures, drugs, and follow-up visits to treat a STI or STl-related disorder identified or diagnosed at a family planning visit (other than HIV/AIDS).

TN No: 15-025 Supersedes TN No. NEW Approval Date - 3/14/16 Effective Date: 7/01/2016

Table of Contents

State/Territory Name: Maine State Plan Amendment (SPA) #: 15-0026 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Approved SPA Pages

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

JFK Federal Building, Government Center

Room 2275

Boston, Massachusetts 02203

CENTERS FOR MEDICARE & MEDICAID SERVICES

Division of Medicaid and Children’s Health Operations / Boston Regional Office

March 3, 2016

Mary Mayhew, Commissioner Department of Health and Human Services 11 State House Station

Augusta, Maine 04333-0011

Dear Commissioner Mayhew:

Enclosed is an approved copy of Maine’s State Plan Amendment (SPA) 15-0026 which was submitted to CMS on December 17, 2015. SPA 15-0026 adds the optional Medicaid eligibility group which provides coverage to women and men that is limited to family planning and family planning-related services under the state plan.

If you have any questions regarding this SPA, please contact Robert Cruz 617-565-1257, or at robert.cruz@cms.hhs.gov.

Sincerely, /s/

Richard R. McGreal Associate Regional Administrator

cc: Stefanie Nadeau, Director, Office of Maine Care Services Sam Senft, Director, Policy, Children’s and Waiver Services Ron Bansmer, Senior MaineCare Program Manager, Office for Family Independence

/s/

Cems Medicaid Eligibility ae

State Name:|Maine | OMB Control Number: 0938-1148

Transmittal Number: ME - 15 - 0026 Eligibility Groups - Options for Coverage $59 Individuals Eligible for Family Planning Services

1902(a)(10)(A)(ii)(XX1) 42 CFR 435.214

Expiration date: 10/31/2014

Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household

income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214.

@ Yes (© No The state attests that it operates this eligibility group in accordance with the following provisions: [B] The individual may be a male or a female. [@] Income standard used for this group

[=] Maximum income standard

The state certifies that it has submitted and received approva! for its converted income standard(s) for pregnant

women to MAGI-equivalent standards and the determination of the maximum income standard to be used for this eligibility group.

An attachment is submitted.

The state's maximum income standard for this eligibility group is the highest of the following:

3 The state's current effective income level for the Pregnant Women eligibility group (42 CFR 435.116) under the Medicaid state plan.

C The state's current effective income level for pregnant women under a Medicaid 1115 demonstration. C The state's current effective income level for Targeted Low-Income Pregnant Women under the CHIP state plan.

C The state's current effective income level for pregnant women under a CHIP 1115 demonstration.

The amount of the maximum income standard is: |209 % FPL

{@] Income standard chosen

The state's income standard used for this eligibility group is: (@ The maximum income standard

C Another income standard less than the maximum standard allowed.

i MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

[i] In determining eligibility for this group, the state uses the following household size:

TN No. 15-0026 Approval Date: 3/3/16 Effective Date: 7/1/16 Maine S$59-1

Supersedes: TN 13-0018

OFFICIAL

Medicaid Eligibility

X] All of the members of the family are included in the household (5 Only the applicant is included in the household (J The state increases the household size by one [Mi] In determining eligibility for this group, the state uses the following income methodology:

5 The state considers the income of the applicant and all legally responsible household members (using MAGI-based methodology).

C The state considers only the income of the applicant. [®] Benefits for this eligibility group are limited to family planning and related services described in the Benefit section. [B] Presumptive Eligibility

The state makes family planning services and supplies available to individuals covered under this group when determined presumptively eligible by a qualified entity.

C Yes (@ No

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

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