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

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

Preamble

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

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

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

Form CMS-R-211

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

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

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

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

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

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

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

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Logan Dreasky

Position/Title: Manager, Eligibility Policy Section Name:

Position/Title: Name:

Position/Title:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14- 26, Baltimore, Maryland 21244.

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

Effective Date: October 1, 2006

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Approval Date: ________________ Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

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

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

1.1.2. Providing expanded benefits under the States Medicaid plan (Title XIX); OR

1.1.3. X A combination of both of the above.

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

Michigan received federal approval to implement MIChild effective May 1, 1998. All claimed expenditure were after May 1, 1998.

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

Michigan complies with the above by including the following statements on the application:

“Neither the DCH nor the FIA will discriminate against any individual or group because of race, sex, religion, age, national origins, marital status, disability or political beliefs.”

“If you need help with this application, call toll free 1-888/988-6300

Spanish: If you need help with this application, call toll free 1-888/988-6300

Arabic: If you need help with this application call toll free 1-888/988-6300”

“If you need help with reading or writing to complete this application, under the Americans with Disabilities Act, you are invited to make your needs known by calling 1-888/988-6300 or your local FIA office.”

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

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“You have the right to appeal a decision made by the DCH or FIA. You will be notified of your rights if your application is denied for any reason.”

1.4

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

Date of Plan Submitted: December 29, 1997 Date Plan Approved: April 7, 1998 State Plan Effective Date: May 1, 1998

Date Amendment #1 Submitted: April 16, 1998 Date Amendment #1 Effective: May 1, 1998

Date Amendment #2 Submitted: December 21, 1998 Date Amendment #2 Effective: January 1, 1999

Date Amendment #3 Submitted: May 28, 1999 Date Amendment #3 Effective: June 28, 1999

Date Amendment #4 Submitted: May 30, 2000 Date Amendment #4 Effective: July 1, 2000

Date Amendment #5 Submitted: August 13, 2001 Date Amendment #5 Effective: July 1, 2001

Date Amendment #6 Submitted: December 20, 2003 Date Amendment #6 Effective: July 1, 2002

Date Amendment #7 Submitted: January 9, 2003 Date Amendment #7 Effective: December 1, 2002

Date Amendment #8 Submitted: June 1, 2005 Date Amendment #8 Effective: November 1, 2005

Date Amendment #9 Submitted: January 16, 2007 Date Amendment #9 Effective: October 1, 2006

Date Amendment #10 Submitted: March 8, 2007 Date Amendment #10 Effective: April 1, 2007

Date Amendment #11 Submitted: March 30, 2010 Date Amendment #11 Effective January 1, 2010

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

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Date Amendment #12 Submitted: August ?, 2010 Date Amendment #12 Effective: October 1, 2010

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

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Approval Date: 6 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

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

State Response: Much attention has been given to the problem of the lack of health insurance coverage for low-income children. Recent efforts to address this problem include various expansions of the Medicaid program and the creation of Title XXI of the Social Security Act. Consistent with Title XXI, Michigan's MIChild program will provide comprehensive health care coverage to all children under age 19 who reside in families whose incomes are at or below 200 percent of the Federal Poverty Level and who are uninsured. In 1998, the Urban Institute estimated that there are 106,000 such children in Michigan. This is the baseline figure used by Michigan as the target for Medicaid or MIChild enrollment.

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

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

State Response: Michigan currently has several programs focused on identifying potentially eligible Medicaid clients and assisting them to complete enrollment forms to become Medicaid recipients. All local health departments in the state have at least two sources of funding specifically for outreach to families and children not currently enrolled in Medicaid and for provision of assistance in applying for Medicaid eligibility.

Medicaid provides funding to all forty-two local health departments so they can identify families with potentially eligible children who are not currently enrolled in Medicaid, assist them in completing enrollment materials, and also assist families in selecting and obtaining access to health care providers serving Medicaid clients. Local health departments utilize a variety of outreach methods including direct mail and telephone contact with families having potentially eligible children, community-based health fairs where preliminary income determination for Medicaid is provided, one-on-one contact with families who seek child health services from the local health department, and a variety of other methods to identify families with potentially eligible children. All local health departments provide transportation arrangements, interpreters for non-English speaking clients, and a variety of in-person, mail and telephone contacts as part of

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

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The other program currently available in all local health departments is the Prenatal Care Enrollment and Coordination Program which provides outreach to facilitate access to prenatal care through the Healthy Kids Program, and assistance in obtaining access to a prenatal care provider. This program also provides families with assistance in completing Medicaid enrollment forms for children, which are then forwarded to Medicaid for determination of eligibility. Services provided through this program include assistance in completion of the shortened MIChild/Healthy Kids enrollment form, gathering all required verifications, negotiating the Medicaid system, obtaining health care providers, responding to managed care problems/concerns, and obtaining access to other support programs.

Several other programs provide outreach for special populations as identified below.

1. Adolescent Health Program/School-Based and School-Linked Health Centers: Teens receiving care in one of the state-funded Teen Health Centers and/or Alternative Models are encouraged to enroll in Medicaid, depending on eligibility, and assisted in the process of enrolling.

2. Early On/Part C of the Individuals with Disabilities Education Act: Since Part C funding represents the last federal dollar that can be spent, assistance with Medicaid enrollment is accomplished through local intermediate school districts and other local human services agencies to assure that eligible children have access to funding sources for health care needs.

3. Infant Support Services Program (ISS): Families of infants with high-risk needs who appear to be Medicaid-eligible are assisted in Medicaid enrollment by the more than one hundred providers throughout the state. Both public and private agencies are ISS providers as are a variety of home health agencies and hospitals in addition to local health departments that provide outreach to high-risk infants to assist them in obtaining services.

4. Maternal Support Services (MSS): Pregnant women and teens who are potentially Medicaid- eligible are assisted in obtaining Medicaid enrollment by providers throughout the state. As with the ISS program, both public and private agencies are providers. This program also provides services to non-Medicaid-eligible women and teens with additional state funding made available for this purpose.

5. Maternal and Infant Health Advocacy Services Program (MIHAS): This program provides outreach to pregnant women who are not currently receiving prenatal care, assists them in dealing with situations which may keep them from remaining in prenatal care, and supports and reinforces the health education messages delivered by health care providers. MIHAS services are delivered by a team of paraprofessional advocates and a supervisor specifically trained to deal with the psychosocial problems of high-risk, low-income pregnant women. Paraprofessional advocates must be indigenous to the community and have been on Medicaid.

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6. Children’s Special Health Care Services Program (CSHCS): CSHCS, through its locally based services (LBS) component, is a major source of outreach activity for children with established and/or potential diagnoses of conditions covered by the program. LBS staff assist families in gathering salary-based information to aid in the determination of eligibility for Medicaid. The majority of children enrolled in this program are funded with a combination of Medicaid and state dollars.

7. Special Supplemental Nutrition Program for Women, Infants and Children (WIC): WIC screens and refers clients to other appropriate health and social services, including Medicaid, food stamps, prenatal care, immunizations, smoking cessation programs, and substance abuse programs. Referral of WIC clients for Medicaid enrollment is a required outreach activity in this program. Nearly half of the infants born in Michigan are served by the WIC Program, making this an important source of outreach for Medicaid enrollment.

8. Medicaid Outreach and Advocacy: For the 1997 local health department Comprehensive Planning, Budgeting and Contracting process, several categorical outreach funding sources and functions have been established as a block grant and have been identified as “Medicaid Outreach and Advocacy.” This block grant is for the specific purpose of identifying individuals/families who are potentially Medicaid-eligible and assisting them in becoming enrolled in Medicaid. Target populations include: pregnant women, families with potentially eligible Medicaid children, families who are eligible for Medicaid but for whom cash assistance is no longer available or delayed due to TANF requirements that are not applicable to Medicaid, and enrollees in Children’s Special Health Care Services who may be Medicaid eligible. Each local health department will be required to develop a plan for the utilization of these block grant funds, including information regarding coordination and collaboration with other community-based organizations, and how cultural, ethnic and racial minorities that reside in each jurisdiction will be targeted.

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

State Response: An example of public-private partnership in health care delivery to children in Michigan was the Caring Program for Children.

Michigan in working with Covering Kids, a national public/private partnership, by providing staffing and materials to promote education and outreach at health-related conferences. The Michigan initiative is called Covering Michigan’s Kids.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable

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

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State Response: As indicated in Section 4 (Eligibility Standards and Methodology) of this state plan application, Michigan will institute thorough eligibility standards and procedures. Our application process will ensure that only children eligible for MIChild and no other creditable health insurance will be enrolled in MIChild. The eligibility application will have specific questions about other health insurance coverage. Periodic sampling of the MIChild enrolled population will be conducted and the sample will be compared to Medicaid and Blue Cross and Blue Shield tapes to assure there is no duplicative coverage. We will also continue all child health activities as described in Section 2.2.1 to ensure that, to the extent possible, all children in Michigan will have access to heath care. Because of the close collaboration we will be establishing with Medicaid Program staff relative to MIChild's eligibility determination process, both Medicaid and MIChild eligibility determinations will be seamless, i.e., referrals and enrollments in either program will be done expeditiously. Based upon review of the completed MIChild application, families will either be referred to Medicaid eligibility processing, enrolled in MIChild, or determined to be ineligible for either program based upon income, access to already existing coverage, or other disqualifying factors.

Section 4.3 on page 20 addresses the issue of coordination with Title V programs under the heading “CSHCS (Children’s Special Health Care Services—Title V) COORDINATION”.

As further indicated in Section 5 (Outreach and Coordination), our efforts in this area will target individual and community awareness of the potential for health care coverage. While our primary outreach goal will be to publicize and to foster enrollment in MIChild, we expect that we will also be increasing recognition relative to other creditable health insurance, particularly Medicaid. We will involve public and private carriers that have knowledge of health care coverage to assist us in these efforts.

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

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Approval Date: 10 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

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

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

State Response: The State expects to have multiple providers offering MIChild medical benefits with a single Administrative Contractor responsible for most MIChild administrative duties and for interacting with the medical benefits providers and the State Department of Community Health.

Licensed health insurers, offering a preferred provider product, and health maintenance organizations (HMOs) will be MIChild medical benefits providers. Plans so qualified may choose to contract with the State as MIChild providers at any time, provided all state qualifying standards are met. The State will require MIChild providers to meet standards beyond ongoing licensure standards. The licensed insurers and HMOs participating in MIChild will perform the following functions:

• They will provide, or reimburse, accessible, quality medical services.

• The Health Plans may determine initial MIChild eligibility prospectively and on the basis of a completed MIChild eligibility application.

(When initial eligibility is determined, the carrier/HMO will advise the Administrative Contractor of the child’s initial eligibility status and forward the MIChild application to the Administrative Contractor for a final determination of MIChild eligibility and State approval.)

(Initial eligibility will be limited to less than two months in duration and will begin on the day the health plan approves the application.)

• They will issue plan cards and membership booklets to qualifying families.

• They will provide MIChild outreach to potential eligibles and market the features of the plan through State-approved normal HMO insurance business activities or as the insurer/HMO otherwise chooses to do.

They will administer a complaint and grievance process for MIChild enrollees. Enrollee families may request a department review through the Insurance Bureau if not satisfied with the outcome of the Insurer's/HMO’s review process.

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Approval Date: 11 MIChild administrative functions will be done by an Administrative Contractor chosen through a Request For Proposals process. The administrative functions will include the following activities: The contractor will perform MIChild outreach activities, primarily through oversight and coordination of subcontracted, locally-based outreach efforts. The administrative functions will include the following activities:

• The contractor will recommend eligibility for MIChild enrollment, based upon review of completed MIChild applications and supporting documentation.

• The contractor will enroll qualifying children in the program with maintenance of supporting eligibility file/data base.

• The contractor will monitor and assess medical carriers’/HMOs’ quality of medical care provision as well as complaint and grievance activities. State staff will interact with the Administrative Contractor on an ongoing basis and will discharge already existing responsibilities relative to the licensed health care insurance providers and HMOs, e.g., adequacy of the carrier’s/HMO’s provider networks.

• The contractor will verify and forward to the State the insurer’s/HMO’s payment requests.

• The Administrative Contractor will collect and keep monthly family premiums.

The existing service delivery systems are involved in the MIChild program. Participating licensed health insurers and HMOs shall be required to include qualified school-based and school-linked adolescent health clinics and Indian health clinics in their networks at standard reimbursement rates when these providers are located in the insurer’s/HMO’s service area. In addition, Michigan has well-functioning service delivery networks that connect children with chronic illnesses and disabilities with services and these are expected to be incorporated in the MIChild service delivery network. As examples:

The Part C-Early On system is specifically focused on the infant/toddler population and is closely linked to Children’s Special Health Care Services (CSHCS), the Infant Support Services Program, and a wide variety of other public and private service agencies at the community level. The perinatal network, which encompasses every hospital in the state that delivers infants, is also closely linked with Early On and CSHCS, as are the Developmental Assessment Clinics that provide follow-up of high-risk (primarily NICU) infants.

Michigan has focused on the implementation of collaborative projects at the local level, including all service agencies and advocacy groups that serve or are interested in the welfare of children. The state directors of the human services departments (Community Health, which includes public health, mental health and Medicaid, as well as the Office on Aging; Education; and the Family Independence Agency, formerly Social Services) have committed to the development and implementation of community-based collaborative efforts and are committed to interagency planning, funding, and management of services at the local level. Multipurpose Collaborative

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The program developed under Title XXI will utilize the current networks described above to publicize the availability of services under MIChild, encourage facilitation of access to enrollment providers, coordinate activities that include assisting families to access the MIChild program, and utilize various transportation, interpreter and other support services to enhance access to health care providers.

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

State Response: The State anticipates a capitation methodology of payment. The State will use its actuarial contractor to establish appropriate rates.

With a risk-based model, the state’s oversight focus will be concentrated on ensuring that needed, quality services are received rather than focusing on issues attendant to service over-use. If the medical services reimbursement mechanism is non risk-based, the State will be equally sensitive to possibilities of service over-use and concerns of accessibility and quality of services received.

Utilization controls/reviews are detailed extensively after Section 7.1 after the heading “State Oversight and Monitoring.”

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

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Approval Date: 14 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

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

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

4.1.1. X Geographic area served by the Plan: Statewide

4.1.2. X Age: Children under 19 years of age

4.1.3. X Income: Above 150 percent and at or below 200 percent of the federal poverty level, depending on the child's age • For children from conception through birth, the adjusted gross income is 0 to 185% of the federal poverty level (FPL). • For children from age 1 to under 19 years of age, the adjusted gross income must be above 150 percent and at or below 200 percent of the FPL. • For children under 1 year of age, the adjusted gross income must be above 185 percent and at or below 200 percent of the FPL.

4.1.4. ∼ Resources (including any standards relating to spend downs and disposition of resources): No resource test

4.1.5. X Residency (so long as residency requirement is not based on length of time in state) : Must be a resident of Michigan or be in Michigan to seek employment.

4.1.6. ∼ Disability Status (so long as any standard relating to disability status does not restrict eligibility): None

4.1.7. X Access to or coverage under other health coverage: Children with comprehensive medical coverage are not eligible for MIChild.

State Response: Comprehensive employer-based coverage by other creditable health insurance will preclude enrollment in MIChild. MIChild enrollment will also be precluded if the applicant was covered by creditable employer-based health insurance within six months of MIChild coverage. However, if the applicant was terminated from creditable employer-based health insurance within six months of making the MIChild application for reasons such as layoff, business closing, or similar circumstance that resulted in the involuntary loss of previous insurance, then MIChild enrollment will not be

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4.1.8. X Duration of eligibility:

State Response: Participating MIChild insurers and HMOs may determine MIChild eligibility on an initial basis if it appears the child will be eligible for MIChild based on review of a completed MIChild application.

The Administrative Contractor will recommend eligibility, with the Department making the final authorization of MIChild eligibility. With approval of the MIChild application, the child will be eligible for twelve months. MIChild eligibility may end prior to twelve months of coverage if the child is found ineligible at audit, turns age 19, moves from the area, or for nonpayment of the MIChild premium.

At the end of the twelve-month eligibility period, the family will be requested to confirm the eligibility information currently on file with MIChild. This information is pre-printed on a standard re-determination form. The family reviews and confirms or changes the information and then signs and returns the form. Following return of the re-determination form, eligibility will be reviewed, and if eligibility continues, the family will be sent payment coupons for another twelve-month period. They will also be sent information advising that if the family income is now lower, the application will be referred for Medicaid determination.

4.1.9. Ξ Other standards (identify and describe): Applicants are required to provide a Social Security Number or they must have applied for SSN. Not required of others.

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

4.2.1. X These standards do not discriminate on the basis of diagnosis. 4.2.2. X Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3. X These standards do not deny eligibility based on a child having a pre- existing medical condition.

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

State Response: The following process will be used to determine eligibility and continued enrollment:

INITIAL START-UP

The Administrative Contractor will have the following responsibilities:

• The contractor will develop: • an application form that is easy to understand, complete, and short, including Arabic and Spanish versions (consistent with Michigan Enrolls’ practice), and • approval/denial eligibility letters.

• The contractor will create and maintain eligibility files that are compatible with DCH data systems. These include, but are not limited to:

• data regarding beneficiaries (e.g., birth dates, sex, race/ethnicity, primary language, social security number), • enrollment dates, • disenrollments (e.g., dates, reasons), and • annual financial re-determinations.

• Upon request, the contractor will provide the MIChild enrolled plans with the applications, processes, and procedures for determining MIChild initial eligibility. The processes and procedures must be approved by DCH.

• The contractor will have a cooperative written agreement with the Children’s Special Health Care Services (CSHCS) Eligibility Division. The agreement will include provisions regarding referrals for potential CSHCS eligible children and enrollment in a qualified health plan for comprehensive health care.

• The contractor will pay all costs associated with the mailing of applications/letters/etc., telephone access (e.g., 1-888 number), maintenance of forms, maintenance of data systems compatible with DCH, and all other costs associated with the eligibility process.

• The contractor will make applications available at local sites (e.g., schools, health departments), and if the application is requested, mail applications to families within two days of request.

• The contractor will collect the monthly premium from the family.

• The contractor will maintain a listing of all MIChild eligibles enrolled by plan, their networks, and MIChild enrollment capacity.

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• The contractor will provide periodic reports to the DCH for the purpose of DCH administrative oversight and monitoring of federal requirements.

• The contractor will provide the family with a creditable certificate of coverage upon disenrollment from MIChild.

• The contractor will perform annual financial re-determinations.

Each plan will have the following responsibilities:

• The Plan will create and issue plan identification cards to be used for those beneficiaries that are MIChild eligible. These require DCH approval prior to use.

• The Plan will create and maintain eligibility files that are compatible with DCH data systems. These include, but are not limited to, data regarding beneficiaries’: 1. identifying information (e.g., address, birth dates, sex), 2. enrollment dates, 3. disenrollments (e.g., dates, reasons), and 4. services provided. . ENROLLMENT PROCESS

Plans that choose to determine initial eligibility will have the following responsibilities:

• receive completed applications and any required verifications,

• within two days of receipt of the completed application, determine initial eligibility for up to two month's of coverage based on information presented,

• follow up on incomplete applications the plan has received by telephone or mail,

• forward applications and eligibility verifications within two days to the Administrative Contractor for final determination of MIChild eligibility,

The Administrative Contractor will have the following responsibilities:

• The Contractor will receive completed applications and any verifications at a central location.

• The Contractor will verify documents (e.g., insurance coverages) and determine eligibility for MIChild based on DCH criteria.

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Approval Date: 18 • The Contractor will process applications, including any required verifications, and mail notices of approvals/disapprovals within ten working days of receipt of the complete application.

• The Contractor will follow up on incomplete applications by telephone or mail.

• The Contractor will perform annual financial re-determinations of eligibility for each beneficiary.

• The Contractor will notify each plan of new MIChild enrollees who were enrolled by the Administrative Contractor.

• The Contractor will make referrals to the Family Independence Agency when the child may be Medicaid eligible. The local Department of Community Health will also be notified of these referrals for follow-up.

• The Contractor will verify the number of MIChild enrollees in each plan for determination of the capitation to be paid to each plan.

RE-ENROLLMENT

Re-application upon disenrollment due to failure to pay premiums is available immediately. Prior to disenrollment, the family will be given an opportunity to explain any changes in income or family size that may now qualify the family for Medicaid.

All other families may enroll in MIChild at any time.

BEGIN DATE OF MICHILD ENROLLMENT

Eligibility for MIChild will depend on the following:

• If the health plan makes an initial determination of eligibility, MIChild eligibility begins the day the health plan approves the application. • If the Administrative Contractor notifies the beneficiary of an eligibility determination, MIChild eligibility begins the first day of the month following the month of approval. Note: For applications processed within five work days of the beginning of the next month, coverage will begin the first of the following month.

ELIGIBILITY LOCK-IN

The MIChild enrollee will be “locked-into” the Contractor for twelve (12) months from the date of enrollment, as long as the child remains MIChild eligible. EFFECTIVE OCTOBER 1, 2010,

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Approval Date: 19 Bbeneficiaries shall have the first 30 90 days of that period to change hHealth AND/or dDental pPlans. MICHILD ENROLLEES WILL HAVE AN ANNUAL OPEN ENROLLMENT PERIOD AND MUST BE NOTIFIED SIXTY (60) DAYS PRIOR TO THE OPPORTUNITY TO CHANGE HEALTH PLAN AND/OR DENTAL PLAN ENROLLMENT. AN beneficiary ENROLLEE may, at any time, change hHealth PLANS AND/or dDental pPlans AT ANY TIME for cause, as determined on an individual basis and approved by the Department.

Reasons for disenrollment will include: • nonpayment of premiums • the beneficiary reaches age 19 • move from area • child is found ineligible at audit • death

The Administrative Contractor must verify that the payment of the premium was made for each month. If the monthly premium for the next month has not been paid, the Administrative Contractor must notify the responsible relative, in writing, of:

• the amount due • the date the past premium must be paid • that the beneficiary will be disenrolled from the plan if the past premium is not paid • the right to request a department review and how to request this review

This notification must be sent to the family at the beginning of the month. If the past premium is not paid within a reasonable time period, the beneficiary will be disenrolled from MIChild, effective the last day of the next month.

The Administrative Contractor must provide the beneficiary with a creditable certificate of coverage upon disenrollment from MIChild.

REDETERMINATION With approval of the MIChild application, the child will be eligible for twelve months. MIChild eligibility may end prior to twelve months of coverage if the child is found ineligible at audit, turns age 19, moves from the area, or for nonpayment of the MIChild premium.

At the end of the twelve-month eligibility period, the family will be requested to confirm the eligibility information currently on file with MIChild. This information is pre-printed on a standard re-determination form. The family reviews and confirms or changes the information and then signs and returns the form. Following return of the re-determination form, eligibility will be reviewed, and if eligibility continues, the family will be sent payment coupons for another twelve-month period. They will also be sent information advising that if the family income is now lower, the application will be referred for Medicaid determination. DCH ELIGIBILITY CRITERIA

In order to be eligible for MIChild:

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

Effective Date:

Approval Date: 20 • The child must be a resident of Michigan, a documented alien, or the family has come to Michigan with the intent to stay or work in Michigan. Some legal immigrants are not eligible for the first five years of residency. Excepted groups include refugees and children of veterans.

Alien status can be verified by the I-551 or I-94. DCH will notify the plans and the Administrative Contractor of the appropriate methods for verifying alien status.

• The child must reside in a family with an adjusted gross income of less than or equal to 200 percent of poverty (185-200 percent of poverty for pregnant women and children under age 1). No asset test is used. The income will be verified by self-declaration.

• The child must be between the ages of 0 and 19 (once the child turns 19, he is no longer eligible for MIChild after the month he turns 19). Emancipated minors must be considered as a family in their own right.

• The child must have no comprehensive employer-based insurance coverage for the past six months. (Specialty insurance coverage such as dental only coverage is not considered a comprehensive insurance.) Coverage through the CSHCS program and the Indian Health Services is not to be considered as other insurance for eligibility purposes.

• The child’s family must have paid the monthly MIChild premiums. Effective July 1, 2001, American Indians/Alaska Natives are exempt from payment of the MIChild premium if any family member listed on the application and living in the home is an American Indian/Alaska Native, even if that member is an adult or a Medicaid recipient.

The following must not be a factor in determining MIChild eligibility

• Disability status • Pre-existing condition • Diagnosis

EXCLUDED CHILDREN

The following individuals cannot participate in MIChild

• children who appear to be eligible for Medicaid (even if not enrolled in Medicaid)

• children who are involuntarily admitted to a non-medical public institution (A public institution means a government-operated facility that does not provide medical care, e.g., jail or prison)

• children who are admitted to an institution for the mentally disabled (e.g., ICF/MR)

• children who are members of a family that is eligible for health coverage under a state health benefits plan on the basis of a family member’s employment by a public agency in Michigan

• children who have had comprehensive employer-based insurance in the past six months, including Medicare, with exception allowed for non-voluntary loss of insurance consistent with HCFA crowd-out policy.

• children who are covered under a group health plan

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

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Approval Date: 21

• children who have court-ordered medical support as part of a divorce settlement (see below)

CSHCS (Children’s Special Health Care Services—Title V) COORDINATION

CSHCS eligibles (non Medicaid) who do not have another source of creditable health care coverage will have a choice of enrolling in either the MIChild Program (that includes specialty services), the CSHCS managed care program with optional supplemental primary coverage, or the fee for service CSHCS program for specialty care only. (The services available under the supplemental primary coverage will ensure that all services available under the MIChild Program are covered through the CSHCS managed care plan.)

• If the family chooses only the MIChild Program, the child will be disenrolled from the CSHCS Program.

• If the family lives in a SHIP county and chooses the CSHCS specialty coverage and MIChild, the child may be enrolled with a CSHCS managed care provider for the specialty services and supplemental primary coverage equivalent to MIChild coverage.

• If the family chooses the fee for service CSHCS program, the child will have specialty coverage only, and that coverage will be through the CSHCS program.

The State will ensure that children currently enrolled in the CSHCS program are given the same choices that newly eligible children are given.

TMA PLUS COORDINATION

TMA Plus is a program operated by the State that allows persons losing transitional Medicaid coverage to buy-in to Medicaid. TMA Plus was originally operated in six Project Zero sites, but has been expanded statewide to afford families that have worked their way off welfare to continue health care coverage if no employer coverage is offered. TMA Plus is only available to families at or below 185 percent of the federal poverty level. TMA Plus families may purchase TMA Plus coverage for the adults and may purchase MIChild coverage for the children.

COURT-ORDERED MEDICAL SUPPORT COORDINATION

If the court has ordered medical support for the child through a divorce settlement, then the child is usually not eligible for MIChild. There are situations when the parent who is responsible for the medical support has not provided that insurance. In these situations, the child may be enrolled in MIChild. The Administrative Contractor must advise the custodial parent that he/she must pursue the court-ordered support. The custodial parent must supply the Administrative Contractor with proof of efforts to obtain that court-ordered support (e.g., Friend of the Court verification).

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

Effective Date:

Approval Date: 22 • If the responsible parent has provided the insurance, then the child must be disenrolled from MIChild.

• If the custodial parent is still in the process of obtaining that insurance, the child may remain on MIChild.

• If the custodial parent has not pursued the court ordered medical support, the child must be disenrolled from MIChild.

SPENDDOWN BENEFICIARIES

A family may be required to meet a spend-down amount to become Medicaid eligible. In these situations:

• the children may be MIChild eligible until the family meets the spend-down amount • anyone in the family may use incurred expenses to meet the spend-down amount • the children on MIChild will not be disenrolled from MIChild • once the family is Medicaid eligible, MIChild will be considered a third party resource • as part of the random sample review, DCH will perform post-payment reviews of spend-down clients and will periodically run the MIChild enrollment list against Medicaid enrollment • data provided to the Administrative Contractor will include a list of spend-down clients by Medicaid ID Number

RETROACTIVE MEDICAID

There may be cases where the child is on MIChild, but Medicaid coverage was made retroactive to cover that same time period. In these cases, the child should be disenrolled from MIChild as soon as he is identified as being Medicaid eligible. A child enrolled in MIChild cannot be retroactively disenrolled from MIChild.

Frequent tape matches between Medicaid and MIChild will be used to minimize this situation.

DEPARTMENT REVIEW PROCESS

Denial of MIChild Eligibility The family may request review of any denial of MIChild eligibility. An attempt will first be made to settle such requests and complaints at the Administrative Contractor level. If the family remains dissatisfied with the decision after having had the opportunity to discuss the matter with supervisory personnel at the Administrative Contractor and they wish to pursue the issue, they may request a Department Review by the DCH for a final decision on the child’s or children’s eligibility.

Denial Letters Denial letters must be sent to the family if MIChild eligibility is denied. The letter must include:

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

Effective Date:

Approval Date: 23 • reason for the denial • family’s right to request an Department Review and the process for that Department Review • the time frames involved • Spanish and Arabic translation

Denial of MIChild Benefits An attempt should be made to settle all complaints at the plan level. If the beneficiary wishes to pursue the issue, he may request a review by the Insurance Bureau. The Administrative Contractor will assist the beneficiary with the process.

QUALITY ASSURANCE/MONITORING

The Administrative Contractor must maintain the following data from the plans for quality assurance purposes. This data must be available in a format that is agreed upon by DCH and the Administrative Contractor. The Administrative Contractor will be required to provide DCH with reports, in formats established by DCH, on a routine basis.

4.3.1 Describe the states policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b)) X Check here if this section does not apply to your state.

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic re-determination, that only targeted low- income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

State Response: The State will perform periodic random reviews and post-eligibility audits of the applications to assure compliance with MIChild eligibility and enrollment policies. In addition, part of the quality assurance methodology will be planned reports on the following:

• list of enrollees by county (this will be compared to the Medicaid population to assure the enrollee is not receiving both Medicaid and MIChild services)

• number of applications received

• number of denials of applications with the reasons for denial

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

Effective Date:

Approval Date: 24 • number of children who were determined by the plans to be MIChild eligible, using presumptive eligibility, who were subsequently determined by the Administrative Contractor not to be MIChild eligible

• number of disenrollments with the reasons for disenrollment

• number of hearings requested and their disposition

• number of CSHCS beneficiaries who have chosen MIChild

• number of annual re-determinations

• enrollee survey results

• corrective actions, with DCH approval, taken with each plan regarding program compliance (e.g., presumptive eligibility)

Application reviews will include assurance that any required verifications have been used, time frames have been met, and appropriate referrals have been made.

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

State Response: Department staff will be available at the time of the Administrative Contractor's review to determine if the child is Medicaid or MIChild eligible.

If the Department determines the child to be Medicaid eligible, the child will NOT be enrolled in the MIChild Program. If the Department determines the child to be ineligible for Medicaid they will have eligibility determined for MIChild. DCH will conduct periodic matches of the MIChild enrollment lists against the Medicaid enrollment lists.

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

If the Department determines the child to be Medicaid ineligible, the application will be reviewed at that time to determine MIChild eligibility.

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

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Approval Date: 25 4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

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

State Response: The MIChild application form will include a request for information regarding other insurance coverage for each child. The contractor will not enroll any child that has creditable employer-based group health coverage or any child who has dropped coverage in the previous six months, unless the reason for dropping the coverage is approved by the state. The fact that employer- based group health coverage was dropped is documented and there is a 6 month waiting period to apply for MIChild if the child has dropped employer-based group health coverage unless the exception criteria is met. BCBS and MIChild HMO’s run monthly matches to insure that enrollees are not subsequently enrolled in the health plans through employer based coverage.

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

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

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

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

The minimum employer contribution.

The cost-effectiveness determination.

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

State Response: Outreach efforts will include the Indian Health Centers and other

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

Effective Date:

Approval Date: 26 agencies providing services to Native Americans. In addition, the local FIA offices are involved in the Indian centers for outreach for Medicaid. If a child is determined not eligible for Medicaid, he will be referred to the MIChild program, if appropriate.

The health plans will involve the Indian Health Centers in its considerations of network providers. This will ensure access to the primary care providers.

The MIChild application form also indicates the American Indian ethnicity in its demographic information requested. Understanding that submitting this information is voluntary; the contractor may use this information to track the number of American Indians that are receiving services through the MIChild program. Targeted outreach may be initiated if necessary. MIChild premiums are waived for any child in a household with an American Indian/Alaskan native member.

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

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Approval Date: 27 Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

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

State Response: The State’s marketing and outreach efforts will be comprised of three components: (1) general marketing through use of demographically targeted media campaigns and existing information dissemination channels; 2) solicitation of cooperation and outreach from programs, agencies, organizations and systems that already know or have potential contact with families likely to have children eligible for MIChild; and 3) solicitation of community-developed plans from each multipurpose collaborative body (MPCB) currently organized in Michigan. Detail of these components follows:

1. General Outreach and Marketing

As part of the comprehensive approach to marketing and outreach of the MIChild program, a statewide media campaign will be conducted, including television, radio, and print. The design of the campaign will be based on the highly successful demographically targeted media campaign the State developed for immunizations. Demographic targeting maximizes the return for advertising dollars by matching the timing and placement of advertisements to the habits of the target population. We anticipate production of two television spots and two radio spots, which will be aired through paid media broadcast as well as through the Michigan Association of Broadcasters. Print media will also run statewide. In addition, collateral pieces, such as brochures and posters, will be developed that provide information regarding the MIChild program and that can be used by communities to reach the target segment. The information available will include an application form for return mailing. All materials will direct readers to a toll free number for further information or questions. Media efforts will be accomplished through the department’s advertising agency of record. In addition, the state will do a kick-off, press event in one or more media markets, as well as quarterly news releases to further expand this outreach effort. The Department maintains a website with current information regarding the MIChild program for access by the general public. At this website, the public may either download and print an application to submit, or may elect to file the electronic application available at this web site.

2. Solicitation of cooperation and outreach from programs/agencies/systems likely to have contact with target families

For agencies and programs under the jurisdiction of, or funded by State agencies, each will be requested to develop a plan for how information on MIChild will be coordinated with current outreach, information dissemination, and marketing efforts and activities.

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

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Approval Date: 28 Because many agencies, programs, organizations, and systems in Michigan already exist that have as their general mission the improvement of the lives of families within the target population (200 percent of poverty), we expect there will be desire on their part to assist in marketing and providing outreach to families with whom they are already in contact and that may have children eligible for MIChild. Below is a preliminary listing of the agencies/programs/organizations/ that were contacted.

3. Development of Community developed plans for outreach and marketing of MIChild

The DCH may provide grants to the fiduciary of the Multipurpose Collaborative Bodies (MPCBs) for each county in which they exist. In exchange for funding, each MPCB will be responsible for the development of a plan reflecting how the resources of their jurisdiction will be dedicated toward marketing and outreach for the MIChild program. The plan will be required to reflect how the following stakeholders in the community will be involved:

Family Independence Agency

Local Public Health

Community Mental Health

Schools

Community Action Agencies

Advocacy organizations

Cooperative Extension

Primary and Migrant Health Centers

Hospitals

Public and private health clinics

Professional associations (e.g. local medical associations, dental associations)

Workforce development boards

Michigan Works agencies (responsible for enrolling Medicaid recipients in managed care programs)

Temporary Employment agencies

Family Courts

Head Start

WIC programs

Child Care coordinating councils

Neighborhood associations

The business community

Churches and other faith-based organizations

Service clubs serving youth (boys and girls clubs, scouting organizations, etc.)

The media (radio, newspapers, TV)

Civic organizations

Food banks

Each MPCB will be requested to identify a “coordinator” for its jurisdiction’s activities to be a liaison with

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

Effective Date:

Approval Date: 29 the State regarding outreach and marketing for MIChild. Training and technical assistance will be made available to communities regarding MIChild. Training and technical assistance needs would be coordinated through this designee. At the end of each fiscal year, the MPCB will provide a report on the activities of the communities under its jurisdiction. It is anticipated that the funds provided will support the activities of the coordinator in his/her efforts to assure that the community plan is carried out and that all efforts are done in a collaborative and coordinated manner.

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: Section 6. Coverage Requirements for Childrens Health Insurance (Section 2103)

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

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

6.1.1. X Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. X FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. X State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.)

State Response: See Addendum 1 for a description of covered services.

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

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

6.1.3. X

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

6.1.4. X Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1. X Coverage the same as Medicaid State plan 6.1.4.2.  Comprehensive coverage for children under a Medicaid Section 1115 demonstration project

6.1.4.3.  Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: 6.1.4.4.  Coverage that includes benchmark coverage plus additional coverage 6.1.4.5.  Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6.  Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7.  Other (Describe)

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

6.2.1. Ξ Inpatient services (Section 2110(a)(1)) 6.2.2. Ξ Outpatient services (Section 2110(a)(2)) 6.2.3. Ξ Physician services (Section 2110(a)(3)) 6.2.4. Ξ Surgical services (Section 2110(a)(4)) 6.2.5. Ξ Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6. Ξ Prescription drugs (Section 2110(a)(6)) 6.2.7. ∼ Over-the-counter medications (Section 2110(a)(7)) 6.2.8. Ξ Laboratory and radiological services (Section 2110(a)(8)) 6.2.9. Ξ Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 6.2.10. Ξ Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11. Ξ Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) 6.2.12. Ξ Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13. Ξ Disposable medical supplies (Section 2110(a)(13)) 6.2.14. ∼ Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15. Ξ Nursing care services (See instructions) (Section 2110(a)(15))

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date:

6.2.16. Ξ Abortion only if necessary to save the life of the mother (Section 2110(a)(16) 6.2.17. Ξ Dental services (Section 2110(a)(17)) 6.2.18. Ξ Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19. Ξ Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20. Ξ Case management services (Section 2110(a)(20)) 6.2.21. Ξ Care coordination services (Section 2110(a)(21)) 6.2.22. Ξ Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23. Ξ Hospice care (Section 2110(a)(23)) 6.2.24. Ξ Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25. ∼ Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26. Ξ Medical transportation (Section 2110(a)(26)) 6.2.27. ∼ Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28. ∼ Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

6.2.-D The State will provide dental coverage to children through one of the following. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (§2103(a)(5)):

6.2.1.-D X State specific dental benefit package. The State assures dental services represented by the following categories of common dental terminology (CDT) codes are included in the dental benefits:

1. Diagnostic 2. Preventive 3. Restorative 4. Endodontic 5. Periodontic 6. Prosthodontic 7. Oral and maxillofacial surgery 8. Orthodontics 9. Emergency dental services

6.2.1.1.-D

Periodicity schedule

Medicaid

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date:

American Academy of Pediatric Dentistry

Other Nationally recognized periodicity schedule

6.2.2.-D Benchmark coverage (§2103(c)(5) and 42 CFR 457.410 and 42 CFR 457. 420) 6.2.3.-D FEHBP-equivalent coverage (§2103(c)(5)(C)(i)) 6.2.4.-D State employee coverage (§2103(c)(5)(C)(ii)) 6.2.5.-D HMO with largest insured commercial enrollment (§2103(c)(5)(C)(iii))

State: Please see Attachment 1 for detail on the above coverages as they relate to children eligible for services under section 6.1.1.2.

State: Please see Attachment 2 for detail on the above coverages as they relate to unborn children eligible for services under section 6.1.4.

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

6.3.1. Ξ The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2. ∼ The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre- existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010)

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

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

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date:

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

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

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: 6.4.2. ∼ Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a)) 6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b)) 6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date:

Section 7. Quality and Appropriateness of Care

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

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

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1. Ξ Quality standards 7.1.2. Ξ Performance measurement 7.1.3. Ξ Information strategies 7.1.4. Ξ Quality improvement strategies

State Response: The State plans to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided by the MIChild Plan, through quality standards, performance measurement information strategies, and quality improvement strategies detailed in the Administrative Contractor Request For Proposal and the MIChild services contract. By contracting for MIChild Plan services with licensed entities, the State believes that it can assure quality and access of care through licensure and oversight activities. The MIChild services will be contracted to Health Maintenance Organizations, Insurance Carriers, and Nonprofit Dental Corporations. Mental health and substance abuse services will be provided through community mental health service programs (CMHSPs) and coordinating agencies (CAs). Both CMHSPs and CAs are public agencies accountable to the department and local government.

Health Maintenance Organizations (Public Act 1978, No. 368 or Michigan Compiled Laws 333.21001)

The State plans to contract with any qualified health maintenance organization providing, when medically indicated, designated health services as described in the terms of the contract. The Department, in conjunction with the Insurance Bureau, has established a system of licensing and regulating of a health maintenance organization that DCH believes pertinent to the readiness of the health maintenance organization to perform MIChild services. Through licensing and regulation activities, the State protects and promotes the public health through the assurance that the organization provides:

• an acceptable quality of health care by qualified personnel • health care facilities, equipment, and personnel which may reasonably be required to economically provide health maintenance services

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: • operational arrangements which integrate the delivery of various services • a financially sound prepayment plan for meeting health care costs

Both the Department and the Insurance Bureau regulate the activities of a health maintenance organization by the following powers and duties:

The Department regulates the health delivery aspects of health maintenance organization operations for the purpose of assuring that the health maintenance organization is capable of providing care and services promptly, appropriately, and in a manner that assures continuity and acceptable quality of health care. The Department may visit or examine the health care service operations of a health maintenance organization and consult with enrollees to the extent necessary to carry out the intent of the Public Act.

The Insurance Bureau regulates the business and financial aspects of health maintenance organization operations for the purposes of assuring that the organization is financially sound and follows acceptable business practices. The Insurance Bureau may visit or examine the business and financial operations of a health maintenance organization to carry out the intent of the Public Act.

The Department and Insurance Bureau have access to the books, papers, and documents of the organization relating to the delivery of health services in a manner which preserves the confidentiality of the health records of individual enrollees. The Department or the Insurance Bureau each shall have access to the corporate books, papers, and documents of the organization relating to the business and finances of the organization.

The State verifies the following documents as part of ongoing review:

• a copy of the basic organizational document of the applicant, such as the articles of incorporation • a copy of the bylaws • a list of the names, addresses, and official positions of individuals responsible for the operation of the HMO • a statement generally describing the organization, its operations, the type and quantity of health professionals engaged to provide services, the location of facilities, and a description of services available at the locations at which health maintenance services will be regularly available to enrollees • a copy of all proposed contracts • a copy of the financial statements • a statement of projected enrollment levels • a statement describing the geographic area serviced by the organization • copies of solicitation materials and a general description of the marketing and enrollment techniques to be employed by the organization, including a plan for informing enrollees of the sources and methods of obtaining services and instructing them in their use • a statement describing the applicant’s procedures for resolving enrollee complaints

Insurance Carrier (Public Act No. 350 of 1980 or Michigan Compiled Laws 550.1020)

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date:

The State plans to contract with any qualified corporation providing a managed health care benefit described in the terms of the contract under a certificate of authority by the Insurance Commissioner. As part of the examination by the Commissioner, the health care corporation shall file with the Office of the Commissioner a number of documents that DCH believes pertinent to the readiness of the corporation to perform MIChild services. The Commissioner shall examine the documents filed and may conduct any investigation which he or she considers necessary, may request additional oral and written information from the incorporators, and may examine under oath any persons interested in or connected with the proposed health care corporation. The documents pertinent to the MIChild Plan that the health care corporation shall file in the Office of the Insurance Commissioner are:

• a statement showing in full detail the plan upon which the corporation proposes to transact business • a copy of all certificates to be issued to subscribers • a copy of the financial statements of the corporation • proposed advertising to be used in the solicitation of certificates for subscribers • a copy of the bylaws • a copy of all proposed contracts and reimbursement methods • a community advisory board

Dental Care Organizations

The State plans to contract with any qualified dental care corporation that chooses to participate under the terms of the contract offered by the state and that provides a dental benefit described in the contract and operating under a certificate of authority by the Commissioner of Insurance. As part of the examination by the Commissioner, the nonprofit dental care corporation files with the Office of the Commissioner a number of documents that DCH believes pertinent to the readiness of the corporation to perform MIChild services. These documents are similar to the before mentioned documents for Health Maintenance Organizations and insurance carriers.

State Oversight and Monitoring

The State expects documentation from the licensed contractors regarding quality and access data collection, analysis, and trending as outlined below.

The plans must submit reports on the quality and access activities of the plans to the DCH. The plan must provide information relative to its enrollment data, HEDIS or HEDIS-like data, appeals, grievances and complaints, and the annual member survey to the Administrative Contractor. The Administrative Contractor analyzes the information submitted by the plans and summarizes the information in reports for the Department. The Department evaluates the information and recommends any corrective action measures necessary as a result of any deficiencies based on analysis of the data submitted. The Department shares the corrective action measures with the plans and monitors their implementation of the corrective actions. The plan will be required to provide other reports as determined necessary by the Department.

Overall it is important that the State have information regarding quality, access, and patient satisfaction

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: relative to the MIChild Plan. The content and format of reports will be finalized with those organizations that successfully contract with the State. The following is a list of items the State expects to monitor through various reports submitted by a contractor.

Enrollment Data Enrollment Demographic Data Income and Resources Data Health Coverage and Type Data, Previous to enrollment and Post-enrollment Reason for Disenrollment Residency Referrals to Medicaid by name and by date of birth

HEDIS or HEDIS-like Data Children’s access to primary care providers Childhood immunization rates Adolescent immunization rates Well-child visits in the first 15 months of life Well-child visits in the third, fourth, fifth and sixth years of life Adolescent well care Physician specialists Membership information Inpatient hospitalizations Ambulatory visits for primary care Ambulatory visits for specialty care Non-acute care visits Maternity care Newborn care Pharmacy Out-of-network care visits Emergency room visits

Dental Data Number of dental exams Number of routine examinations Number of cleanings Number of restorations Number of sealants Number of emergency visits Number of simple extractions

Mental Health and Substance Abuse Data will be monitored through the Community Mental Health Service Programs and the Coordinating Agencies responsible for the provision of these services.

Data Validation

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: The plan must agree to cooperate with the Department in carrying out validation of data provided by the plan and its subcontractors and by making available medical records and a sample of its data and data collection protocols. The plan must also agree to the development and implementation of corrective action plans to correct data validity problems as identified by the Administrative Contractor.

Grievance and Complaint Reporting The plan must establish and maintain a complaint system which affords adequate and reasonable procedures for the expeditious resolution of written complaints initiated by members concerning any matter relating to the provisions of a service. A plan, within 30 days after receipt of a written complaint, shall give a reasonable written response to each complaint which it receives. The plan shall maintain a complete record of all the written complaints of its members which the plan has received since the date of the last report. This record shall indicate the total number of complaints; and by line of business, the nature of each complaint, the disposition of each complaint, and the time taken to process each complaint.

A plan shall submit to the MIChild Administrative Contractor an annual report which describes the complaint system of the corporation, and includes a compilation and analysis of the written complaints filed with the plan, their disposition and underlying causes, and measures being implemented to alleviate those causes. An analysis of the grievances shall include the total number of grievances resolved in favor of the member; number of grievances resolved in favor of the plan, and at what level the grievance was resolved.

At a minimum, procedures shall be developed by a plan for the resolution of claims for reimbursement; denial, cancellations, or non-renewals of certificates; and complaints regarding the quality of the services delivered by health care providers and health care facilities which receive reimbursement from the plan.

The report shall be compiled in a manner which protects an individual’s right to privacy with respect to medical information and shall not disclose the identity of a member by name or other personal identifier without the member’s consent. The annual report shall be a public record.

Appeals The Department requires that the contractor follow the appeal guidelines described in the State’s Patient Bill of Rights.

Member Satisfaction Survey The Department requires that the contractors utilize the Consumer Assessment of Health Plans Survey (CAHPS) or CAHPS-like for completion of the member satisfaction survey. The survey must be designed to measure and report information regarding the following categories:

● ease of identifying a provider ● waiting time for an appointment ● phone waiting time for medical advice ● access to assessment, tests, treatment and specialists ● emergency room use ● ease of referral to specialists ● follow-up reminders

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date:

Evaluation of Outreach The contractors and local agencies receiving outreach funding must submit reports on the outreach efforts.

The MIChild Plan will use quality standards, performance measures, information strategies, and quality improvement strategies to ensure high-quality care for MIChild enrollees. Table 1 is a list of the MIChild Plan quality methods and tools.

The State’s contract(s) with a health carrier and/or plan will require them to collect and report enrollment, HEDIS or HEDIS-like, CAHPS, complaint, appeal, outreach, and dental (dental plan only) data. If it has an adequate quantity of children with continuous enrollment, the MIChild Plan contractor will produce these measures for its provider network either directly or through a contractor.

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: Table 1. List of MIChild Plan Quality Methods and Measurement Tools

METHODS (including TOOLS BY WHOM Performance Measurement Strategies):

Review of Quality & Access Member Satisfaction Survey Contractors

Quality and Access Study DCH

Enrollment Data Contractors

Appeal Reporting DCH & Insurance Bureau Internal Review of Quality and Access

Grievance Reporting Contractor and DCH State Health Registers, e.g., Immunization Data Validation Administrative Contractor & DCH

HEDIS or HEDIS-like Plans & Administrative Contractor

Quality Standards:

Licensure Patient Bill of Rights, Public Health Codes and Insurance Code State Contract Standards Access Standards, e.g., emergency room DCH

Information Strategies:

Provider Education Sharing performance measurement results DCH

Sharing Clinical Practice Standards Contractor RFP - Administrative Contract Purchasing specs (capacity)

Competitive Bids for Administrative functions of the MIChild Plan DCH Enrollee Education Enrollee Handbook - Rts & Responsibilities Contractors Ongoing Contract Monitoring MIChild Contract DCH

Consumer Education Contractor

Quality Improvement

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: Strategies: Feedback to Plans on Quality and Access Corrective Action Plans DCH

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

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

State Response: See Chart below

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

State Response: See Chart below

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

State Response: See Chart below

A. The State assures access to covered services in the following manner:

Carrier Plan MICHILD ACCESS ASSURANCES X X MIChild contracts will establish and maintain MIChild services statewide. A contractor may provide MIChild services statewide or at a minimum geographic area defined as a county. X X The MIChild contracts allow plans to provide services based upon presumptive eligibility for two months for children eligible for MIChild as the Administrative Contractor approves the final MIChild application. X X The MIChild contracts require the plan and Administrative Contractor to refer all Medicaid-eligible children to the State. X X The MIChild administrative contract requires the Administrative Contractor to refer the application of a likely Medicaid-eligible child to the Family Independence Agency to assist the family in the Medicaid application process. X X The MIChild services contract will specify that the contractor must reimburse for medically necessary services that include pediatric sub- specialists in the network of providers including (but not limited to): allergist, cardiac surgeon, cardiologist, critical care specialist,

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: dermatologist, endocrinologist, gastroenterologist, nutrition specialist, geneticist, hematologist/oncologist, immunologist, infectious disease specialist, neonatologists nephrologist, neurologist, neurosurgeon, ophthalmologist, orthopedist, otolaryngologist, psychiatrist, pulmonologist, rheumatologist, surgeon and urologist. X X The MIChild contract will require the plans to reimburse medically necessary services for out of the area or out of the plan’s network of providers. X X The contractor must have written procedures/protocols for emergency medical services for children. These must be consistent with MIChild contract language. X X The contract will require the disclosure of any physician incentive plan. X X The contractor must describe covered benefits and enrollee rights/responsibilities in an enrollee handbook (to include but not limited to the State contract language requirements for enrollee handbook).

B. The State will assure access through the following monitoring activities:

Carrier Health Plan MICHILD ACCESS MONITORING ASSURANCES X X The State requires the contractor to annually submit HEDIS 3.0 or HEDIS-like data, e.g., the children-appropriate sections. NA NA The State requires the contractor to annually submit enrollment data and Medicaid referral data. X X The State requires the contractor to do an annual member satisfaction survey. X X The State requires the contractor to maintain and report grievances and complaint logs. X X The State performs a quality and access study through a contractor. X X The State requires the contractor to maintain a complaint log and resolution status of complaint. X X The State analyzes the appeal reports from the Insurance Bureau X X The State performs evaluations and reports as noted in Section 10.

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

State Response: The State intends to contract the MIChild Plan with any qualified health carrier or plan

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: that is licensed and meets the Department’s participation standards. The State’s contract for the MIChild Plan will incorporate access standards, including emergency services. The Request for Proposals for the Administrative Contractor will include eligibility and enrollment responsibilities and monitoring duties regarding enrollments by the plans.

Health Plans issue Membership handbooks to their members that detail the procedures for prior authorization of health care. For services that require Prior Authorization, enrollees are informed that in most cases, the health plan will approve, deny or partially approve/deny a request for prior approval within 15 days of receipt. In urgent cases, response will be within 72 hours. Prior authorization of services is acknowledged in state law at MCL 5000.2212a.

Model Application Template for the State Childrens Health Insurance Program Effective Date: April 1, 2007 Page: Approval Date: Section 8. Cost Sharing and Payment (Section 2103(e))

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

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

8.1.1. Ξ YES 8.1.2. ∼ NO, skip to question 8.8.

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

8.2.1. Premiums:

State Response: For families in the MIChild program, with incomes above 150% of the Federal Poverty Level (or above 185% of the Federal Poverty Level if the enrollee is less than age one) the family will be required to pay $10.00 per month, per family. However, the premium is waived if the fiscal group includes a member who is an American Indian/Alaskan native.

8.2.2. Deductibles:

State Response: Michigan will assess no deductibles.

8.2.3. Coinsurance or co-payments:

State Response: Michigan will assess no coinsurance amounts or co-payments.

8.2.4. Other: None

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

State Response: Enrollment and outreach material will contain a notice and description of cost sharing.

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

8.4.1. x Cost-sharing does not favor children from higher income families over

Model Application Template for the State Childrens Health Insurance Program Effective Date: April 1, 2007 Page: Approval Date: lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2. x No cost-sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3 x No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

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

State Response: Cost sharing will only apply to MIChild enrollees in families with incomes above 150 percent of the Federal Poverty Level (or above 185 percent of the Federal Poverty Level if the enrollee is less than age one). The cost sharing involves only a monthly premium of $10. This amount is never in excess of 5% of an eligible family’s income. If a family’s income is such that $10 exceeds 5% of their monthly income, the family would be eligible for Medicaid (with no premium) and not MIChild.

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

State Response: See Section 8.2.1 and 4.4.5

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

State Response: The Administrative Contractor must verify that the payment of the premium was made for each month. If the monthly premium for the next month has not been paid, the Administrative Contractor must notify the responsible relative, in writing, of:

• the amount due • the date the past premium must be paid • that the beneficiary will be disenrolled from the plan if the past premium is not paid • the right to request a department review and how to request this review

This notification must be sent to the family at the beginning of the month. If the past premium is not paid within a reasonable time period, the beneficiary will be disenrolled from MIChild, effective the last day of the next month.

Re-enrollment after failure to pay is available immediately. Prior to disenrollment, the family will be given an opportunity to explain any changes in income or family size that may now qualify the family for Medicaid. Applicants that do not have unpaid MI Child premiums in the past 6 months will have a 1-month grace period to pay the initial monthly premium. Applicants that have an unpaid balance for one or more of the preceding 6 months will be required to pay all past due premiums prior to

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: being re-enrolled in MI Child.

New enrollees with no past due premiums are given a one-month grace period to ensure that they have ample time to pay the premium, prior to being terminated. After an initial notice of the amount due, individuals failing to pay prior to the due date are sent a reminder notice mid-month indicating that if payment is not received by the due date in the next month, coverage will be terminated. The grace period is only given to new enrollees to ensure that failure to pay is not the result of a misunderstanding or unfamiliarity with the program.

All other families may enroll in MIChild at any time.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied to all enrollees: X State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, co-payments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a)) X The disenrollment process affords the enrollee an opportunity to show that the enrollees family income has declined prior to disenrollment for non payment of cost-sharing charges. (42CFR 457.570(b)) X In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the childs cost-sharing category as appropriate. (42CFR 457.570(b)) X The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

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

8.8.1. Ξ No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2. Ξ No cost-sharing (including premiums, deductibles, co-pays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3. Ξ No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4. Ξ Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5. Ξ No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: mother. (Section 2105)(c)(7)(B)) (42CFR 457.475)

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

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

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

State Response: The strategic objective of the MIChild program is to increase the number of low income children in Michigan with creditable employer-based health insurance coverage by means of moving the children under age 19 without health insurance into either accessible, quality Medicaid or MIChild coverage while not simultaneously “crowding out” existing private coverage.

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

State Response:

Goal 1. Continue to enroll the uninsured, low income children in Michigan in either the Medicaid program or the MIChild program, as appropriate.

Goal 2. Obtain accurate, usable HEDIS or HEDIS-like reports from MIChild providers and monitor the following outcomes with emphasis on:

• well child examinations • immunizations • receipt of at least one (1) physician visit per MIChild enrollee annually • receipt of at least one (1) dental examination per MIChild enrollee annually

Goal 3. Local agencies and programs will contact low-income families representing 106,000 uninsured children and make known to the families the availability of Medicaid and MIChild health insurance coverage.

Goal 4. Provide an application and enrollment process which is easy for families to understand and use.

Goal 5. Obtain the participation of community-based organizations in outreach and education activities.

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

State Response:

Goal 1. Count the number of children enrolled in the Medicaid program at the beginning of MIChild program implementation and at twelve months after MIChild program implementation, and add the difference to the number of MIChild enrollees after twelve months of MIChild implementation. Compare

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: this number to the base number.

Goal 2. Require MIChild insurers and HMOs to report HEDIS or HEDIS-like data to the State, work with these contractors to insure accuracy and timeliness of reporting, and assess the reported service counts against state goals.

Goal 3. Require local agencies receiving MIChild outreach funding to report to the State the number of target families contacted.

Goal 4. Assess the family’s satisfaction survey.

Goal 5. The state will assess the extent to which community-based organizations participate in the MIChild outreach effort.

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4)) 9.3.1. Ξ The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2. Ξ The reduction in the percentage of uninsured children. 9.3.3. ∼ The increase in the percentage of children with a usual source of care. 9.3.4. Ξ The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5. Ξ HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6. ∼ Other child appropriate measurement set. List or describe the set used. 9.3.7. ∼ If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. ∼ Immunizations 9.3.7.2. ∼ Well child care 9.3.7.3. ∼ Adolescent well visits 9.3.7.4. ∼ Satisfaction with care 9.3.7.5. ∼ Mental health 9.3.7.6. ∼ Dental care 9.3.7.7. ∼ Other, please list: 9.3.8. ∼ Performance measures for special targeted populations.

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: 9.4. Ξ The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

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

State Response: The Michigan Department of Community Health will perform the annual assessments and evaluations required in Section 2108 (a). The annual report will include an assessment of the MIChild Plan and its progress toward meeting its strategic objectives and performance goals.

Beginning March 31, 2000, the State will submit an annual evaluation that includes the following elements as specified in Section 2108 (b).

A. The State will submit an evaluation of the effectiveness of the MIChild Plan in increasing the number of children with creditable health coverage. One of the plan’s strategic objectives is to decrease the number of uninsured children in Michigan. The effectiveness of the plan in meeting this goal will be evaluated by comparing the number of children in families with incomes of 200 percent or less of the Federal Poverty Level who are uninsured and the number of children newly eligible for Medicaid and the MIChild program.

B. The State will submit a description and analysis of the effectiveness of the elements of the State plan, including:

1. Demographics: The demographic characteristics of the children and families assisted under the State plan will be identified, including age of the children, family income, ethnicity, primary language, and the child’s coverage by other health insurance prior to MIChild eligibility.

2. Quality: The quality of health coverage provided including the types of benefits provided. The State will measure quality as described in Section 7.1 and 7.2. Effectiveness will be determined by the extent to which strategic objective performance goals are met.

3. Subsidies and Cost-Sharing: The report will identify the amount of assistance provided by the State and the premium paid by the families of the enrollees.

4. Service area: The State offers MIChild coverage on a statewide basis. County-specific data is collected by the Administrative Contractor awarded the bid.

5. Time Limits: MIChild Plan enrollees are to be enrolled for twelve months of eligibility. The reports will analyze to what extent children received coverage for the full twelve months. If possible, the reason for disenrollment before twelve months will be obtained and evaluated.

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date:

6. Benefits Covered and other Methods Used to Provide Health Assistance: The State will evaluate the benefits covered annually and determine additions or deletions based on the State’s employee health plan as a benchmark coverage.

7. Sources of Non-Federal Funding: The sources of non-federal funding used in the MIChild Plan will be described and detailed in the assessment.

C. An assessment of the effectiveness of other public and private programs in the state in increasing the availability of affordable quality individual and family health insurance for children is not within the scope of the State to be able to perform.

D. The State will review and assess State activities to coordinate the MIChild Plan under this title with other public and private programs providing health care and health care financing, including Medicaid and maternal and child health services.

E. The report will analyze changes and trends in the State that affect the provision of accessible, affordable, quality health insurance and health care to children.

F. As part of the reports, the State will assess and make recommendations for improving the program under this title.

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

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

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

9.8.1. Ξ Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2. Ξ Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3. Ξ Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4. Ξ Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

Ongoing Public Involvement:

• Public and private individuals and entities have the opportunity to offer input on the implementation of MIChild on an ongoing basis through the Department of Community Health’s Health Plans Advisory Committee. In addition, the Department maintains an extensive list of individuals and entities that will receive the agendas and minutes of the Advisory Committee. The Advisory Committee meets monthly and subscribers receive agendas and minutes as meetings are scheduled and held.

• The Department requests comments from the general public as a routine part of the policy bulletin promulgation process. After the internal comment period, copies of all proposed policy bulletins are distributed to a statewide mailing list of interested parties, including advocates, local health agencies, and tribal centers. All returned comments are given consideration in the development of the final policy language.

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

State Response: See Section 9.9

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

State Response: See Section 9.9

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: 9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

 Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment.  Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

MIChild Budget Assumptions

Budget Neutrality. These changes made to the state plan are budget neutral.

Payments to Benefit Contractors. Premiums for health, vision, and dental coverage are estimated to be $90 per month. Enrollment in FY 01 reached 30,053 children by the end of the fiscal year. Average monthly enrollment for FY 01 was 27,178 children. For FY 2003 and beyond, the state hopes to achieve enrollment of 90 percent of the total number of eligible children. Average monthly enrollment in MIChild is estimated to be 34,000 children for FY 2003 and beyond.

Mental Health and Substance Abuse Services. Mental health and substance abuse services will be arranged through local Community Mental Health Service Programs (CMHSPs) and local Substance Abuse Coordinating Agencies (CAs). These entities are especially suited to serve this population because of their expertise and experience working with low-income populations. Funding for these services will be provided through state allocations to these local entities for the MIChild population.

Administrative Oversight. The Department of Community Health (DCH) will use the competitive bid process to contract with a private company to provide administrative services and eligibility recommendations for the MIChild program. An estimate of the cost of this contract has been included in the budget, but has not been explicitly broken out to prevent potential contractors from using it as a target for their bid. Michigan will minimize state administrative costs through the use of community agencies and the Administrative Contractor. DCH staff will provide appropriate contract monitoring and necessary oversight to ensure accountability for the program.

Payments for Outreach. The State will conduct a demographically-targeted advertising campaign to announce the MIChild program and to increase public awareness of the opportunity for enrollment in the program. Additional funds will be used to conduct training seminars for advocacy and other community- based agencies involved in the outreach effort. The budget for these functions is estimated at $250,000 per year. Local agencies in each community will be provided outreach grants to fund the development of an outreach plan for the community and providing an assessment of the community’s success in enrolling children in MIChild.

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date:

This reporting period: Federal Fiscal Year 2010. This is a combination budget.

COST OF APPROVED SCHIP PLAN

Benefit Costs Reporting Period 2010 Next Fiscal Year

2011 Following Fiscal Year 2012 Insurance payments

Managed Care

Per member/Per month rate @ # of eligibles 96,369,384 69,281,836 117,587,970 Fee for Service 39,186,550 27,304,000 28,123,120 Total Benefit Costs 135,555,934 96,585,836 145,711,090 (Offsetting beneficiary cost sharing payments) (2,758,405) (3,162,841) (3,257,726) Net Benefit Costs 132,797,529 93,422,995 142,453,364

Administration Costs

Personnel

General Administration 519,842 352,248 362,815 Contractors/Brokers (e.g., enrollment contractors) 3,932,104 4,675,811 4,816,085 Claims Processing

Outreach/Marketing costs

Other

Total Administration Costs 4,451,946 5,028,059 5,028,059 10% Administrative Cap (net benefit costs ÷ 9) 14,755,281 10,380,333 15,828,151

Federal Title XXI Share 101,880,285 73,080,217 109,475,460 State Share 35,369,190 25,370,837 38,005,963

TOTAL COSTS OF APPROVED SCHIP PLAN 137,249,475 98,451,054 147,481,423

Non-Federal source of funding: State Appropriations (General Fund)

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750) 10.1.1. Ξ The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and Below is a chart listing the types of information that the state’s annual report might include. Submission of such information will allow comparisons to be made between states and on a nationwide basis.

Attributes of Population

Number of Children with Creditable Coverage XIX OTHER CHIP

Number of Children without Creditable Coverage

TOTAL

Income Level:

< 100%

< 133%

< 185%

< 200%

> 200%

Age

0 - 1

1 - 5

6 - 12

13 - 18

Race and Ethnicity

American Indian or Alaskan Native

Asian or Pacific Islander

Black, not of Hispanic origin

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: Hispanic

White, not of Hispanic origin

Location

MSA

Non-MSA

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

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

10.3-D X The State agrees to submit yearly the approved dental benefit package and to submit quarterly the required information on dental providers in the state to the Human Resources and Services Administration for posting on the Insure Kids Now! Website.

Model Application Template for the State Childrens Health Insurance Program Effective Date: Page: Approval Date: Section 11. Program Integrity (Section 2101(a))

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

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

State Response: Procurement of Administrative Contractor is effected through Request for Proposal (RFP) bid process. Any HMO or PPO licensed by the state may be a provider.

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1. Ξ 42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2. Ξ Section 1124 (relating to disclosure of ownership and related information) 11.2.3. Ξ Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4. Ξ Section 1128A (relating to civil monetary penalties) 11.2.5. Ξ Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6. Ξ Section 1128E (relating to the National health care fraud and abuse data collection program)

Effective Date:

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

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

Eligibility and Enrollment Matters

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

State Response: Eligibility and Enrollment issues are addressed in detail in Section 4. The Department maintains a website where the public may either download and print an application to submit, or may elect to file the electronic application available at this web site. Submitting an electronic application yields an immediate decision and is the most efficient means of expediting an application. If a person does not have online access, they may be assisted at a local health department in having the information entered for them.

The state provides opportunities and imposes standards for review of eligibility and enrollment decisions in accordance with 42 CFR 457.1120 – 42 CFR 457.1180.

Each applicant/enrollee is provided with the necessary request forms allowing them to challenge decisions regarding: l) The denial of eligibility 2) Failure to make a timely determination of eligibility 3) Suspension or termination of enrollment, including disenrollment for failure to pay cost sharing. The review request forms are sent to the applicant/enrollee at the same time as the notification of the denial/termination decisions. The review request forms include directions for completing the review request form, the mailing address for submitting the review request and a toll-free phone number for assistance in completing the review request form.

The State ensures that the applicant/enrollees in the medical programs receive impartial reviews of all matters pertaining to eligibility/enrollment by referring requests for reviews of the action taken to persons not directly involved in the matter under review. Representatives of the Department of Community Health conduct the formal review of the outside contractor’s actions. Neither department representative has been directly involved in the disputed action/decision under review. The Quality Assurance Analyst with the Department of Community Health reviews the action taken by the contractor and determines if the contractor’s actions were in compliance with the stated policy. The analyst then presents their findings to the Department of Community Health Hearings Officer. The hearings officer determines if the denial/termination should be upheld or overturned based on the findings of the analyst. The applicant/enrollee is then notified of the decision.

In matters of Medicaid eligibility/enrollment, terminations of Medicaid are suspended if the request for review is received prior to the termination date. The applicant/enrollee continues to receive Medicaid until the decision is rendered by the Administrative Law Judge. There is no cost sharing involved with the Medicaid programs.

Enrollees/applicants are given timely written notice of any denial/termination of eligibility. The notification includes the reason for the determination, an explanation of the applicant’s rights to review of the decision, the standard and expedited time frames for requesting a review. The applicant/enrollee is also advised of their right

Effective Date:

Page: Approval Date: to review a decision and provided with instruction on how to request a review and how to continue current eligibility while the review is pending along with a contact phone number (including a number for individuals with hearing and speech difficulties) to request assistance in completing the review request. A review may be expedited if there is a stated immediate need for health services.

Health Services Matters

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

(a) State Response: Health services are delivered through licensed HMO’s and PPO’s Contractual requirements addressing (among other things) the review process for health services matters is based on Public Act 1978, No. 368 or Michigan Compiled Laws 333.21001. Section 7 also addresses this issue. The state is using a standard statewide review to ensure that an enrollee has an opportunity for external review of a-- (1) Delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services; and (2) Failure to approve, furnish, or provide payment for health services in a timely manner.

Premium Assistance Programs

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

ADDENDUM 1 All services must be determined to be medically necessary and provided through a managed care environment.

Second Surgical Opinion Consultations are covered when recommended by a physician or desired by the enrolled member or member’s representative.

Home Health Care is covered for 120 days per calendar year for home health care provided through a Medicare-certified home health care agency when:

• the member is confined to home, • the member’s physician recommends home health care, and • the member’s physician prepares a treatment plan.

Home health care visits do not reduce the available benefit for hospital days. Covered home health care benefits include the following:

• nursing care by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) if the

Effective Date:

Page: Approval Date: services of an RN are not available, • home health aide services, such as meal preparation, bathing and feeding (with a 4 hour visit being defined as a "day"), • nutritional guidance and social services, • medical and surgical supplies, such as catheters, colostomy supplies and hypodermic needles, • oxygen, laboratory services and drugs, • physical, speech, and occupational therapy.

Hospice Care is covered when all of the following conditions are met:

• a physician certifies that the patient is terminally ill (that is, the person has been diagnosed as having six months or less to live); • the patient chooses to receive care from a hospice instead of standard benefits for the terminal illness; and • care is provided by either a Medicare or BCBSM-certified hospice program for both Medicare and non-Medicare enrollees.

The Plan will cover up to 210 days--two periods of 90 days each, and one period of 30 days--during the patient's lifetime. Covered hospice care benefits include the following:

• nursing care by or under the supervision of a Registered Professional Nurse (RN); • home health aide and homemaker services; • short-term inpatient care; • medical supplies and drugs; • physical, speech and occupational therapy; • medical social services (including needs assessment, psychological and dietary counseling); and • bereavement counseling for the family for up to 30 days following the patient's death.

Inpatient Hospital admissions are covered up to 365 days per benefit year including the following services and supplies:

• semi-private rooms and intensive care units, • meals and special diets, • general nursing services, • use of operating, delivery and other treatment rooms, • birthing center services, • anesthesia when administered by an employee of the hospital, • laboratory and pathology examinations, • chemotherapy for the treatment of malignant and non-malignant disease, • oxygen and other gas therapy, • drugs, biologicals and solutions, • diagnostic and therapeutic x-rays, EKGs, cobalt, isotopes, radiation therapy, CAT and MRI

Effective Date:

Page: Approval Date: scans, • routine nursery care of the newborn when the mother is eligible for maternity care, • dental and related anesthesia expenses in a hospital when a concurrent hazardous health condition exists, and • hospital-billed ambulance service.

Mental Health Services are covered when arranged through a Community Mental Health Service Program. Services may include:

• inpatient care up to 365 days per benefit year, • outpatient treatment, • alternative treatment as deemed medically appropriate by the CMHSP, including client services management, • prescription drugs related to mental health, • laboratory/diagnostic tests related to mental health.

Substance Abuse Services are covered when medically necessary, as determined by a Substance Abuse Coordinating Agency.

Emergency treatment is covered without prior authorization if medically necessary, as defined in state statute.

Outpatient Hospital is covered for the following services:

• emergency room services for accidental injuries treated within 48 hours of the injury, • emergency room services for an illness or disease if the condition is life- threatening (emergency room services are covered for emergencies only), • surgery, • hemodialysis, • chemotherapy, • diagnostic laboratory, x-ray and EKG services, • preadmission testing within 72 hours of inpatient admission, • termination of pregnancy when determined medically necessary to save the life of the mother, and • special hospital programs including home hemophilia and home hemodialysis.

Pediatric Well-Child Care is covered for the following services:

• Physician office visits for well-baby care from a child’s birth to age 24 months; • Physician office visits for physical examinations for a child 24 months to age 19 years (maximum one exam every 12 months); • Immunizations from a child’s birth to age 19.

Effective Date:

Page: Approval Date: Skilled Nursing Facility benefits are covered up to 120 days per admission for skilled care in a skilled nursing or extended care facility while convalescing from general conditions and pulmonary TB including:

• semi-private room, • meals and special diets, • nursing services, • use of special treatment rooms, • x-ray and laboratory examinations, • physical, speech and occupational therapy, • oxygen and other gas therapy, • drugs, biologicals and solutions, and • materials used in dressings and casts.

After benefit days have been exhausted, they are renewed when there has been a lapse of at least 90 days from discharge date until the next admission date.

Physician and other professional provider services and medical/surgical supplies and services including the following:

• physicians charges for office and clinic visits and office consultations for the diagnosis or treatment of an injury, illness or disease, • surgery, • blood, • blood storage when the member donates in preparation for scheduled surgery, • cataract surgery and first lens implant(s), • technical surgical assistance when an intern, resident or house officer is not available or qualified, • inpatient medical care, • anesthesia and oxygen, • treatment of accidental injuries if treated within 48 hours of injury, • emergency medical treatment of an illness if the patient is admitted directly from the emergency room or within 72 hours of illness, • family planning services as defined within the MIChild benefit, • termination of pregnancy when determined medically necessary to save the life of the mother, • inpatient consultations including outpatient consultations, • diagnostic and therapeutic EKG, x-ray, radium, isotope and radiation therapy, • diagnostic laboratory and x-ray examinations including CAT and MRI scans, • allergy testing, • dermatology, • hemodialysis, • chemotherapy, • chiropractor x-rays, • certain dental work or oral surgery

Effective Date:

Page: Approval Date: • private duty skilled care nursing charges, except such care if provided by a person who ordinarily resides in your home or who is a member of your family or the family of your spouse, • allergy extract and extract injection, • papanicolaou (PAP) test once every 12 consecutive months, • physical, occupational and speech therapy, • prenatal and post natal care visits, • contraceptive devices (one per year) requiring a prescription or physician insertion/removal, • first contact lens(e.g.) obtained within one year of cataract surgery, • chelation therapy for certain diagnosis, and • eye and ear examinations for the diagnosis of an illness or injury.

Chiropractic Care benefits are as follows:

• manipulations, • an initial office examination, • x-rays relating to back and spine, • first aid treatment of musculoskeletal injury are when performed by a physician, including a chiropractor acting within the scope of licensure.

Acupuncture therapy treatments are covered up to a maximum of 20 in a calendar year when performed by (not just under the direction of) a physician (M.D. or D.O.) for the treatment of any one of the following illnesses:

• Sciatica • Neuritis • Post Herpetic Neuralgia • Tic Douloureaux • Chronic Headaches, e.g., migraine • Osteoarthritis • Rheumatoid Arthritis • Myofascial complaints, e.g., neck and lower back pain

Outpatient Psychiatric Care and Outpatient Substance Abuse Treatment Services are covered for the outpatient diagnosis, evaluation or treatment of mental and nervous conditions including such conditions as or relating to alcoholism or drug abuse when arranged through a CMHSP or a Substance Abuse Coordinating Agency as appropriate for the diagnosis being treated. For this outpatient mental/nervous benefit, services are provided by:

• a psychiatrist (M.D.); • a psychologist (fully licensed); • a limited licensed psychologist or a social worker at the masters degree level (M.S.W. or C.S.W.) or higher, if acting in accordance with a treatment plan reviewed at least every 6 months by a

Effective Date:

Page: Approval Date: psychiatrist or fully licensed psychologist and/or if providing services under the direction of a psychiatrist or fully licensed psychologist; or • an alternate provider as deemed appropriate by the CMHSP.

Therapeutic Services are covered at home of member or outside of home if necessary equipment cannot be brought into the home.

• Physical Therapy • Speech Therapy • Occupational Therapy

Durable Medical Equipment is covered on a rental or purchase basis when:

• it is reasonably and medically necessary for the treatment of illness, injury or disease, • prescribed by a physician and used in the course of medical treatment, and • purchased from a professional supplier.

Repair of Purchased Durable Medical Equipment is covered due to normal wear and tear.

Replacement of Purchased Durable Medical Equipment is covered due to the following:

• the loss or irreparable damage of your equipment; or • a change in your condition or size.

Prosthetic and Orthotic Appliances are covered when prescribed by a physician (within the scope of his or her license) as medically necessary. Prosthetics are defined as artificial and/or mechanical appliances (such as arms, legs, eyes, etc.) which replace all or part of the functions of a permanently inoperative or real functioning body organ. Orthotics are defined as appliances which support or straighten a deformed body part. Coverage includes:

• prosthetic and orthotic appliances which are pre-fabricated or custom-fitted, • the repair, fitting and/or adjustment of a covered prosthetic or orthotic appliance, • the replacement of appliances when they are damaged beyond repair or worn out, or because of a change in the child’s condition or size.

Organ and Tissue Transplants are covered including hospital and professional medical services required to receive a non-experimental transplant of a human organ or body tissue. Transplants of artificial organs are not covered. Coverage includes hospital, surgical and laboratory and x-ray expenses incurred by the person donating an organ or tissue to an enrolled member.

Orthopedic Shoe Inserts are covered when prescribed by a physician.

Hearing Care is covered for the following services and supplies payable once in every 36 consecutive months:

Effective Date:

Page: Approval Date:

• Audiometric examination to measure hearing ability, including tests for air conduction, bone conduction, speech reception and speech discrimination, • Hearing aid evaluation tests to determine what type of hearing aid(s) should be prescribed to compensate for loss of hearing, • Hearing Aids including in-the-ear, behind-the-ear, and on-the-body designs, and Binaural Aids purchased together, • Dispensing fees for the normal services required in the fitting of a hearing aid, • Hearing aid conformity tests to evaluate the performance of a hearing aid and its conformity to the original prescription after the aid has been fitted.

Hearing care benefits are not payable for hearing aid repairs or for the replacement of parts (including batteries and ear molds). Benefits are also not payable for the replacement of lost or broken hearing aids unless the 36 month coverage limitation does not apply.

Vision Care is covered for the following services:

• annual vision exam • annual glaucoma testing • eye glasses once every 24 months or once every 12 months with a prescription change

Pharmacy is covered for each prescription drug or refill purchased up to a 34-day supply. Certain medications can be covered in a 100 unit dosage or 34-day supply (whichever is greater) or a 200 unit dosage or 34-day supply (whichever is greater).

Prescription are to be filled with a generic medication unless prescribing physician has indicated "dispense as written" ("DAW') on the prescription.

Benefits cover the following:

• a drug, biological or compounded medication which, by federal law, may be dispensed only by prescription and which is required to be labeled “Caution: Federal Law Prohibits Dispensing without a Prescription”, • injectable insulin, • hypodermic syringes or needles prescribed by an attending physician, and • birth control prescriptions.

The following are not covered benefits:

• any drug entirely consumed at the time and place it is prescribed, • the administration or injection of any drug, • any refill of a drug if it is more than the number of refills specified by the prescription, • any refill of a drug dispensed more than one year after the latest prescription for that drug, • any drug which is provided while the member is an inpatient in a facility,

Effective Date:

Page: Approval Date: • any drug provided on an outpatient basis in any facility if benefits are paid under any other part of the plan, and • over-the-counter drugs available without a prescription.

Weight Loss Clinic attendance is covered for morbid obesity when prescribed by a physician.

Ambulance Services are covered as follows:

• Hospital-billed ambulance service for a trip to or from the hospital, a skilled nursing facility or member’s home, or

• Professional ambulance service when used to transport the member from the place where injured to the first hospital where treatment is given.

Dental Benefits include at a minimum, preventive, diagnostic and basic restorative services.

Maximum Annual Benefit $1500 calculated on a fee schedule basis. When medically necessary and prior approved, additional services are covered on a case by case basis. Clinical exams recommended by age 1; required by age 3 and every 6 months thereafter X-rays covered Fillings covered Fluoride Treatments 2x year, up to age 19 Prophylaxes 3x year Sealants 1st permanent molar, up to age 9 2nd permanent molar, up to age 14 1 per 3 years per tooth Extractions simple and surgical Oral Surgery – including maxillofacial surgery covered, including pre- and post- operative care the excision of teeth partly or completely impacted in the bone of the jaw, the excision of teeth that will not erupt through the gum, the excision of other teeth that cannot be removed without cutting into bone, the excision of a tooth root without extracting the entire tooth, but not including root canal therapy, the treatment of a jaw fracture, dislocation or wound, the treatment of cysts, tumors or other disease tissues, apicoectomy, other incision or excision procedures on the gums and tissues of the mouth when not performed in connection with tooth repair or extraction, the alteration of the jaw, jaw joints or bite relationships by a cutting procedure when appliance therapy alone cannot result in functional improvement. Endodontics covered Periapical Services covered Periodontics covered Crowns 1 per tooth per 5 years Veneers Covered for medical necessity: - severe tetracycline staining

Effective Date:

Page: Approval Date: - severe fluorosis - hereditary opalescent dentin - ameleo-genesis imperfecta Prosthodontics covered Relines/Repairs covered Orthodontics when medically necessary with prior approval* Emergency dental services covered

*Requests for prior approval must be initiated by the dentists. The dentist submits photos and x-rays along with a narrative of required services to the professional services section. The request for special consideration is reviewed by professional staff and a determination is sent back to the requesting provider.

Effective Date:

Page: Approval Date: Draft Preprint- Addition of SCHIP Coverage for Prenatal Care and Associated Health Care Services to the State Child Health Plan

State/Territory:

MICHIGAN (Name of State/Territory)

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

4.1.2.1 Age: from conception through birth

4.1.3.1 Income: 0 % of the FPL (and not eligible for Medicaid) through 185 % of the FPL

Effective Date: December 1, 2002 (date costs begin to be incurred)

Implementation Date: December 1, 2002 (dates services begin to be provided)

Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.10. Please provide a l-year projected budget for all targeted low-income children covered under the state plan using the attached financial form. Additionally, please provide the following:

• Total I- year cost of adding prenatal coverage: $6,000,000

• Estimate of unborn children covered in year 1: 5,163

Effective Date:

Page: Approval Date:

ATTACHMENT 2

Medical service coverage for unborn children is limited to the following prenatal and pregnancy-related services. All pregnancy-related services must be determined to be medically necessary. Services will be provided on a fee-for-service basis.

Prenatal Care

Maternal Support Services (MSS)

Note: Pre-pregnancy family services and supplies are not covered for unborn children,

Labor and delivery: Professional services fee, including live birth, miscarriage, ectopic pregnancy, and stillborn.

Radiology and ultrasound

Childbirth education

Laboratory

Pharmaceuticals and prescription vitamins

Inpatient Hospital for Delivery Only

Outpatient Hospital

Note: Outpatient deliveries are not covered.

MICHIGAN'S TITLE XXI PLAN SUMMARY FACT SHEET

Name of Plan:

MIChild Date of Plan Submitted:

December 29, 1997 Date Plan Approved:

April 7, 1998 State Plan Effective Date:

May 1, 1998

Date Amendment #1 Submitted:

April 16, 1998 Date Amendment #1 Approved:

June 29, 1998 Date Amendment #1 Effective:

May 1, 1998

Date Amendment #2 Submitted:

December 21, 1998 Date Amendment #2 Approved:

March 31, 1999 Date Amendment #2 Effective:

January 1, 1999

Date Amendment #3 Submitted:

May 28, 1999 Date Amendment #3 Approved:

August 27, 1999 Date Amendment #3 Effective:

June 28, 1999

Date Amendment #4 Submitted:

May 30, 2000 Date Amendment #4 Approved:

November 7, 2000 Date Amendment #4 Effective:

July 1, 2000

Date Amendment #5 Submitted:

August 13, 2001 Date Amendment #5 Approved:

November 14, 2001 Date Amendment #5 Effective:

July 1, 2001

Date Amendment #6 Submitted:

December 20, 2003 Date Amendment #6 Approved:

February 21, 2003 Date Amendment #6 Effective:

July 1, 2002

Date Amendment #7 Submitted:

January 9, 2003 Date Amendment #7 Approved:

April 17, 2003 Date Amendment #7 Effective:

December 1, 2002

Date Amendment #8 Submitted:

June 1, 2005 Date Amendment #8 Approved:

December 6, 2005 Date Amendment #8 Effective:

November 1, 2005

Date Amendment #9 Submitted:

January 16, 2007 Date Amendment #9 Withdrawn:

July 23, 2007

Date Amendment #10 Submitted:

March 8, 2007 Date Amendment #10 Approved:

July 19, 2007

Date Amendment #10 Effective:

April 1, 2007

Date Amendment #11 Submitted:

March 30, 2010 Date Amendment #11 Approved:

June 10, 2010 Date Amendment #11 Effective:

January 1, 2010

Date Amendment #12 Submitted:

August 26, 2010 Date Amendment #12 Approved:

October 29, 2010 Date Amendment #12 Effective:

October 1, 2010

Background

• On December 29, 1997, Michigan submitted a title XXI State plan in order to implement a new State Child Health Insurance Program called "MIChild." The program was implemented on May 1, 1998, and provided coverage to children under age 19 in families with incomes up to 200 percent of the Federal poverty level (FPL).

• Prior to May 1, 1998, Michigan's Medicaid program provided coverage to pregnant women and infants up to age 1 in families with incomes at or below 185 percent of the FPL and all children ages 1 to 15 up to 150 percent of the FPL.

Title XXI Amendments

• Michigan submitted its first amendment on April 16, 1998. This amendment expanded Medicaid eligibility to children 16 through 18 years of age in families with incomes through 150 percent of FPL; reduced premiums and eliminated copayments; required final eligibility determinations to be made by State staff, and established a 12-month lock-in to health plans.

• Michigan submitted its second amendment on December 21, 1998. This amendment removed sterilization and infertility treatments as covered services and revised the open enrollment policy.

• Michigan submitted its third amendment on May 28, 1999. This amendment established that abortions are covered under the program only when determined medically necessary to save the life of the mother.

• Michigan submitted its fourth amendment on May 30, 2000. This amendment allowed self-declaration of income and modified the reenrollment process.

• Michigan submitted its fifth amendment on August 13, 2001. This amendment clarified technical language, eliminated open enrollment periods, allowed families to explain changes in income or family size before disenrolling for failure to pay, initiated the exemption to premiums for American Indians/Alaska Natives and initiated collection of ethnicity and primary language data.

• Michigan submitted its sixth amendment on December 20, 2002. This amendment updated and amended its SCHIP state plan to indicate the State’s compliance with the final SCHIP regulations.

• Michigan submitted its seventh amendment on January 9, 2003. This amendment added coverage for unborn children with family incomes up to and including 185 percent of the FPL and not eligible for Medicaid. Coverage will include prenatal care and associated health services for children from conception through birth.

• Michigan submitted its eighth amendment on June 1, 2005. This amendment eliminated the 6-month disqualification period for failure to pay premiums and updated the scope of benefits for physician services.

• Michigan submitted its ninth amendment on January 16, 2007. This amendment proposed to limit the use of title XXI funds to the separate child health program, discontinuing the use of those funds for an SCHIP combination program.

• Michigan submitted its tenth amendment on March 8, 2007. This amendment increased the monthly premium from $5 to $10 per family.

• Michigan submitted its eleventh amendment on March 30, 2010. This amendment updated dental services to come into compliance with CHIPRA.

• Michigan submitted its twelfth amendment on August 26, 2010. This amendment expands the annual open enrollment period from 30 days to 90 days and provides enrollees 60 days notice of the open enrollment period.

Children Covered Under the Program

• The State reported that 72,035 children were ever enrolled in SCHIP during Federal fiscal year 2009.

Administration and Phases

• Michigan has a single administrative contractor that is responsible for most MIChild administrative duties. Final eligibility determination is made by State staff.

• The Administrative Contractor is responsible for interacting with the medical benefits providers and the State Department of Community Health.

Health Care Delivery System

• Michigan has multiple managed care providers offering MIChild medical benefits. Licensed insurers that offer a preferred provider product and health maintenance organizations may choose to contract with the State at any time, provided that all the State standards are met.

Benefit Package

• The benefit package for MIChild is the same as the State employee benefit package. The benefit package is a comprehensive benefit package that includes a variety of hospital and physician services.

Cost Sharing

• Michigan does not impose any copayments.

• Michigan charges premiums for children in families with incomes between 151 and 200 percent of the FPL. The premium is $5 per month regardless of the number of children in the family. Families with members who are American Indians and Alaska Natives are exempt from the premium payment.

State Action to Avoid Crowd Out

• The MIChild application form includes a request for information regarding other insurance coverage for each child. The contractor does not enroll any child who has creditable group health coverage or any child who has dropped coverage in the previous 6 months, unless the reason for dropping the coverage is approved by the State. Families that have employer- sponsored coverage available to them, but who are not availing themselves of this coverage, are not enrolled in MIChild.

Coordination between SCHIP and Medicaid

• Michigan uses a single application, and children who are found eligible for Medicaid are enrolled in Medicaid. A child who is eligible for Medicaid is ineligible for MIChild.

• State eligibility workers are available at the time of the Administrative Contractor's review to determine if the child is Medicaid or MIChild eligible.

Outreach Activities

• The State's marketing and outreach effort is comprised of three components: general marketing through the use of demographically targeted media campaigns and existing information dissemination channels (demographic targeting maximizes the return for advertising dollars by matching the timing and placement of advertisements to the habits of the target population) and the solicitation of cooperation and outreach from programs/agencies/systems/associations likely to have contact with target families.

Financial Information

Total FFY 2010 SCHIP Allotment – $231,491,565

FFY ’10 Enhanced Federal Matching Rate – 74.23%

Date Last Updated: November 9, 2010

_____________________________________________________________________________ Table of Contents State/Territory Name: Michigan State Plan Amendments (SPA) #: MI-13-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Michigan consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES a

Centers for Medicare & Medicaid Services Ca

7500 Security Boulevard, Mail Stop: S2-26-12 CM 4 ‘CENTERS FOR MEDICARE & MEDICAID SERVICES,

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

OCT 0 9 2014

Stephen Fitton, Director

Medical Services Administration

Michigan Department of Community Health ‘ 400 South Pine Street, P.O. Box 30479

Lansing, MI 48909-7979

Dear Mr. Fitton:

I am writing to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number MI-13-0001, submitted on December 20, 2013, with additional information submitted on March 7, July 11, and October 8, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility, and it has an effective date of January 1, 2014.

In SPA number MI-13-0001, with regard to MAGI Eligibility and Methods, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP-covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low-income children, and page CS9 indicates that the state will cover children from conception to birth when the mother is not eligible for Medicaid.

We are enclosing a copy of the approved CS7, CS9, and CS15 SPA pages. The state should incorporate page CS15 within a separate subsection under section 4.3 of Michigan’s approved CHIP state plan. The enclosed CS7 and CS9 pages supersede the current Geographic Area, Age, and Income sections 4.1.1, 4.1.2, and 4.1.3 of the current CHIP state plan.

Your title XXI project officer is Ms. Kathy Cuneo. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Cuneo’s contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-5913

Facsimile: (410) 786-5882

E-mail: Kathleen.Cuneo@cms.hhs.gov

Page 2 - Mr. Stephen Fitton Official communications regarding program matters should be sent simultaneously to Ms. Cuneo and to Ms. Verlon Johnson, Associate Regional Administrator (ARA) in our Chicago Regional Office. Ms. Johnson's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations 233 North Michigan Avenue, Suite 600 Chicago, IL 60601 If you have additional questions or concerns, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs, at (410) 786-0719. We look forward to continuing to work with you and your staff toward the approval of your remaining CHIP MAGI Eligibility SPAs. Enclosures cc: Sincerely, Eliot Fishman Director Ms. Verlon Johnson, ARA, CMS Region V, Chicago

Children’s Health Insurance Program Eligibility

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Michigan

name: 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. |Mi-13-0001

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

Proposed Effective Date

(an/2a/ yyy)

Federal Statute/ Regulation Citation

[42 GFR 457.10, 310, 315 and 320; 2102(b)(1)(B)(v) of the SSA

Federal Budget Impact This SPA has a budget impact. Total budget impact: State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count: 80 out of 2000

This SPA sets the MAGI income standards for all covered groups in separate CHIP.

Signature of State Agency Official

Submitted By: Loni Hackney

Last Revision Jul 11, 2014 Date:

Submit Date: Dec 20, 2013

CHIP Eligibility

OMB Control Number: 0938-1148 Xxpiration date: 10/3 1/2014 2102(b)(1)(BXv) of the SSA and 42 CFR 457.310, 315 and 320 rl Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards ‘established by the state. The CHIP Agency operates this covered group in accordance with the following provisions: Age Must be under age 19. Income Standards Income standards are applied statewide. | Yes Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard? Statewide Income Standards Begin with lowest age range first. Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here. From Age To Age Above (% FPL) Up to & including (% FPL) 1 195 212 OK 19 160 212 : xX Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards. Newborns up to one year of age have a Medicaid FPL of 195%. The Medicaid FPL for 1-19 year old beneficiaries is 160%. Special Program for Children with Disabilities Does the state have a special program for children with disabilities? PRA Disclosure Statement SPA# MI-13-0001 Approval Date: OcT 0 9 2014 Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

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

V.201 30709)

OCT 9.9 2014

SPA# MI-13-0001 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148 Expiration dat (31/2014

42 CFR 457.10

[i] Coverage From Conception to Birth - Coverage from conception to birth when the mother is not eligible for Medicaid. [YZ] The CHIP Agency operates this covered group in accordance with the following provisions: Age Standard

From conception through birth.

Does the state have an additional age definition or other age-related conditions? {No

Income Standards

Income standards are applied statewide. Yes

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

Statewide Income Standard

The statewide income standard is: From zero up to [195 | % FPL

fi Exempted from requirement of providing or applying for a Social Security Number.

{@ Exempted from requirement of verifying citizenship status.

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

SPA# MI-13-0001 Approval Date: OCT 9.9 2014 Effective Date: January 1, 2014 Page I of |

2102(b)(1)(B)(v) of the SSA and 42 CFR 457,315

CHIP Eligibility

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

A

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

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

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

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

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

Household income includes actually available cash support. exceeding nominal amounts. provided

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. pres

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

PRA Disclosure Statement

SPA# MI-13-0001 Approval Date: OCT 0 9 2044 Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

SIME TOR MEEACARN 4 AARC ERNIE

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

OCT 0 9 2014

SPA# MI-13-0001 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Michigan State Plan Amendments (SPA) #: MI-13-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Michigan consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop: S2-01-16 < M Ss Baltimore, Maryland 21244-1850

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

Children and Adults Health Programs Group

MAR 17 2014

Stephen Fitton, Director

Medical Services Administration

Michigan Department of Community Health 400 South Pine Street, P.O. Box 30479 Lansing, MI 48909-7979

Dear Mr. Fitton:

lam writing to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number MI-13-0003, submitted on December 20, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility, with an effective date of January 1, 2014.

SPA number MI-13-0003 describes the state’s plan to provide coverage in its separate CHIP for children subject to section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is enclosed, and this should be incorporated within a separate subsection under section 4.1 of Michigan’s approved CHIP state plan.

Your title XXI project officer is Ms. Kathy Cuneo. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Cuneo’s contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-5913

Facsimile: (410) 786-5882

E-mail: Kathleen.Cuneo@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Cuneo and to Ms. Verlon Johnson, Associate Regional Administrator (ARA) in our Chicago Regional Office. Ms. Johnson’s address is:

Page 2 - Stephen Fitton Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations 233 North Michigan Avenue, Suite 600 Chicago, IL 60601 If you have additional questions or concerns, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining CHIP MAGI Eligibility SPAs. Enclosure cc: Sincerely, Eliot Fishman Director Ms. Verlon Johnson, ARA, CMS Region V, Chicago

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance

Program Eligibility

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Michigan

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

with leading zeros. The dashes must also be entered. [MI-13-0003

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

Proposed Effective Date

(n/a yyy)

Federal Statute/ Regulation Citation

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

Federal Budget Impact This SPA has a budget impact. Total budget impact: State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count:120 out of 2000

Establishes a new coverage group for children who lose Medicaid eligibility as a result of discontinuation of disregards

Signature of State Agency Official

Submitted By: Loni Hackney

Last Revision Dec 20, 2013 Date: Submit Date: Dec 20, 2013

BACK CONTINUE)

MSs CHIP Eligibility

CENTER RACES HARD NIC

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

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

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

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

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.3 10(d). Coverage for this population will cease when the last child protected

* from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage ina separate CHIP (expected to be no later than April 1, 2016 ).

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

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

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

% FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

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

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

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

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid program. MAR i t 20% Effective Date: January 1, 2014

Page | of 2

SPA# MI-13-0003 Approval Date:

CMs. CHIP Eligibility

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

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

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

MAR 17 2014

SPA# MI-13-0003 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Michigan State Plan Amendments (SPA) #: MI-15-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Michigan consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

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

7500 Security Boulevard, Mail Stop $2-01-16 Baltimore, MD 21244-1850

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

Children and Adults Health Programs Group

MAR 0 8 2016

Chris Priest, Director

Medical Services Administration

Michigan Department of Health and Human Services 400 South Pine Street, P.O. Box 30479

Lansing, MI 48909-7979

Dear Mr. Priest:

The Centers for Medicare & Medicaid Services (CMS) is approving your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendments (SPA) MI-15-0002, MI-15-0003 and MI-15-0004, submitted on December 17, 2015. CMS issued a Request for Additional Information (RAI) on February 24, 2016. CMS received Michigan’s official response to our RAI on March 7, 2016.

These amendments transition the majority of children enrolled in the state’s separate CHIP to a Medicaid expansion program. Effective January 1, 2016, the following populations will now receive coverage under a Medicaid expansion program:

e Children from birth to age one with family income above 195 percent of the federal poverty level (FPL) up to and including 212 percent of the FPL,

e Children from age one to six with family income above 143 percent of the FPL up to and including 212 percent of the FPL, and

e Children from age six to 19 with family income above 109 of the FPL up to and including 212 of the FPL.

The only children remaining in the separate CHIP are children from conception to birth, as defined in 42 CFR 457.10, with family income up to and including 195 percent of the FPL.

MI-15-0002

Through CHIP SPA MI-15-0002, the state eliminated references that are no longer applicable for children that moved from its separate CHIP to its Medicaid expansion program as this population will now be described in the Medicaid state plan. Coverage for children from conception to birth remains unchanged.

MI-15-0003

Through CHIP SPA MI-15-0003, the state amended its existing MAGI-equivalent standards, by age and income level, for children up to and including 212 percent of the FPL covered in its title XXI-funded Medicaid expansion program. This state plan page (CS3) will allow the state to claim title XXI match against its CHIP allotment for children who transitioned to its Medicaid expansion program.

Page 2 - Mr. Chris Priest MI-15-0004 Through CHIP SPA Ml-15-0004, the state clarified on the CS21 state plan page that premiums and enrollment fees are not applicable to the remaining conception to birth eligibility category. Your title XXI project officer is Mr. Patrick Edwards. He is available to answer questions concerning these amendments and other CHIP-relatedissues. Mr. Edwards' contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-15 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-6643 Facsimile: ( 410) 786-5882 E-mail: Patrick.Edwards@cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Mr. Edwards and to Ms. Ruth Hughes, Associate Regional Administrator (ARA) in our Chicago Regional Office. Ms. Hughes' address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations 233 North Michigan A venue, Suite 600 Chicago, IL 60601 If you have additional questions or concerns, please contact Mr. Manning Pellanda, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff. Enclosures Anne Marie Costello Acting Director cc: Ms. Ruth Hughes, ARA, CMS Region V, Chicago ..

Control Panel

General Information

File Management

Tribal Input

Summary

Children's Health Insurance

Program Eligibility

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Michigan

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

with leading zeros. The dashes must also be entered. [MI-15-0003 |

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

Proposed Effective Date

(am/aa/yyyy)

Federal Statute/ Regulation Citation

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

Federal Budget Impact This SPA has a budget impact. Total budget impact: State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes.

Character Count:121 out of 2000

odifies the MAGI-based income standards for CHIP Medicaid Expansion due to transition from MICHILD to Medicaid Expansion

Signature of State Agency Official

Submitted By: Erin Black

Last Revision Dec 17, 2015 Date:

Submit Date: Dec 17, 2015

CHIP Eligibility .

State Name:|Michigan OMB Control Number: 0938-1148 Transmittal Number: MI - 15

- 0003 Expiration date: 10/31/2014

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

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

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) 1 195 212 6 143 212 19 109 212

PRA Disclosure Statement .

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

V.20140415

SPA# MI-15-0003 Approval Date: MAR 0 8 2016 Effective Date: January 1, 2016 Page | of |

_____________________________________________________________________________ Table of Contents State/Territory Name: Michigan State Plan Amendments (SPA) #: MI-19-0020-CHIP This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 € M Ging,

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

Children and Adults Health Programs Group

OCT 10 2019

Kate Massey

Director, Medical Services Administration and Medicaid Michigan Department of Health & Human Services

400 South Pine Street

Lansing, MI 48913

Dear Ms. Massey:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number MI-19-0020-CHIP, submitted on May 23, 2019, has been approved. This SPA permits Michigan to modify its current health services initiatives (HSIs) to provide lead abatement services in the homes of low-income children and pregnant women effective January 1, 2019 and its poison control HSI effective August 1, 2019.

This SPA modifies Michigan’s lead abatement HSI by permitting the state to require certain rental property owners to contribute toward lead abatement work completed on rental properties. The SPA also documents the change in administrator for Michigan’s Poison Control Center from Children’s Hospital of Michigan to Wayne State University.

Section 2105(a)(1)(D)(ii) of the Social Security Act (the Act) and 42 CFR §457.10 authorize use of title XXI administrative funding for expenditures for health services initiatives (HSI) under the plan for improving the health of children, including targeted low-income children and other low-income children. Consistent with section 2105(c)(6)(B) of the Act and 42 CFR §457.626, title XXI funds used to support an HSI cannot supplant Medicaid or other sources of federal funding.

The state shall ensure that the remaining title XXI funding, within the state’s 10 percent administrative limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of this HSI to the administration of the CHIP program. The state shall report annually to CMS the expenditures funded by the HSI for each federal fiscal year. The state shall also continue to report at a minimum quarterly to CMS any metrics regarding the implementation of the HSI as agreed to by the state and CMS.

Your title XXI project officer is Ms. Dietrich Graham. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Graham’s contact information is as follows:

Page 2 — Ms. Kate Massey

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 233 N. Michigan Avenue, Suite 600 Chicago, IL 60601

Telephone: (312) 353-9355

E-mail: Dietrich.Graham@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Graham and to Ms. Ruth Hughes, Deputy Director in our Medicaid Field Operations North Division. Ms. Hughes’ address is:

Centers for Medicare & Medicaid Services Medicaid Field Operations North Division 233 North Michigan Avenue, Suite 600 Chicago, IL 60601

If you have additional questions or concerns, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs, at (410) 786-0721.

We look forward to continuing to work with you and your staff. Sincerely, . /signed Anne Marie Costello/

Anne Marie Costello Director

ce: Ms. Ruth Hughes, Deputy Director, Medicaid Field Operations North Division

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 1

OMB #: 0938-0707 Exp. Date:

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

Preamble

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

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

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

Form CMS-R-211

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 2

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

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

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

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

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

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

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Logan Dreasky

Position/Title: Manager, Eligibility Policy Section Name:

Position/Title: Name:

Position/Title:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14- 26, Baltimore, Maryland 21244.

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 3 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

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

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

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

1.1.3. X A combination of both of the above.

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

Michigan received federal approval to implement MIChild effective May 1, 1998. All claimed expenditures were after May 1, 1998.

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

Michigan complies with the above by including the following statements on the application:

Michigan Department of Health and Human Services (MDHHS) will not discriminate against any individual or group because of race, sex, religion, age, national origins, marital status, disability or political beliefs.”

“If you need help with this application, call toll free 1-888/988-6300

Spanish: If you need help with this application, call toll free 1-888/988-6300

Arabic: If you need help with this application call toll free 1-888/988-6300”

“If you need help with reading or writing to complete this application, under the Americans with Disabilities Act, you are invited to make your needs known by calling 1-888/988-6300 or your local FIA office.”

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 4

“You have the right to appeal a decision made by the MDHHS. You will be notified of your rights if your application is denied for any reason.”

1.4

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

Date of Plan Submitted: December 29, 1997 Date Plan Approved: April 7, 1998 State Plan Effective Date: May 1, 1998

Date Amendment #1 Submitted: April 16, 1998 Date Amendment #1 Effective: May 1, 1998

Date Amendment #2 Submitted: December 21, 1998 Date Amendment #2 Effective: January 1, 1999

Date Amendment #3 Submitted: May 28, 1999 Date Amendment #3 Effective: June 28, 1999

Date Amendment #4 Submitted: May 30, 2000 Date Amendment #4 Effective: July 1, 2000

Date Amendment #5 Submitted: August 13, 2001 Date Amendment #5 Effective: July 1, 2001

Date Amendment #6 Submitted: December 20, 2003 Date Amendment #6 Effective: July 1, 2002

Date Amendment #7 Submitted: January 9, 2003 Date Amendment #7 Effective: December 1, 2002

Date Amendment #8 Submitted: June 1, 2005 Date Amendment #8 Effective: November 1, 2005

Date Amendment #9 Submitted: January 16, 2007 Date Amendment #9 Effective: October 1, 2006

Date Amendment #10 Submitted: March 8, 2007 Date Amendment #10 Effective: April 1, 2007

Date Amendment #11 Submitted:

March 30, 2010 Date Amendment #11 Effective

January 1, 2010

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 5

Date Amendment #12 Submitted:

August 28, 2010 Date Amendment #12 Effective:

October 1, 2010

Date Amendment #13 Submitted:

September 28, 2011 Date Amendment #13 Effective:

October 1, 2010

Date Amendment #14 Submitted:

February 21, 2013 Date Amendment #14 Effective:

April 1, 2013

Date Amendment #15 Submitted:

October 4, 2013 Date Amendment #15 Withdrawn:

October 14, 2013

Date Amendment #16 Submitted:

March 21, 2014 Date Amendment #16 Effective:

July 1, 2014

Date Amendment #MI-15-0001-CHIP Submitted: March 31, 2015 Date Amendment #MI-15-0001-CHIP Withdrawn: June 4, 2015

Date Amendment #MI-15-0002-CHIP Submitted: December 17, 2015 Date Amendment #MI-15-0002-CHIP Effective: January 1, 2016

Date Amendment #MI-16-0017-CHIP Submitted: November 3, 2016 Date Amendment #MI-16-0017-CHIP Effective: January 1, 2017

Date Amendment #MI-17-0018-CHIP Submitted: September 7, 2017 Date Amendment #MI-17-0018-CHIP Effective: January 1, 2017

Date Amendment #MI-18-0019-CHIP Submitted: August 8, 2018 Date Amendment #MI-18-0019-CHIP Effective: October 2, 2017

Date Amendment #MI-19-0020-CHIP Submitted: May 23, 2019 Date Amendment #MI-19-0020-CHIP Effective for lead abatement HSI:

January 1, 2019 Date Amendment #MI-19-0020-CHIP Effective for Poison Control HSI:

August 1, 2019

Superseding Eligibility Pages of Modified Adjusted Gross Income (MAGI) CHIP State Plan Material State: Michigan

Transmittal Number SPA Group PDF # Description Superseded Plan Section(s)

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

Transmittal SPA Group PDF # Description Superseded Plan Number Section(s) MI-13-0001 MAGI CS7 Eligibility — Supersedes the Eligibility & Targeted Low current sections Date Submitted: Methods Income Children 4.1.1, 4.1.2 and 4.1.3 12/20/13 Approval Date: Eligibility — Supersedes the 10/09/14 Ccs9 Coverage from current sections Effective/Implemen Conception to Birth | 4.1.1, 4.1.2 and 4.1.3 tation Date: January 1, 2014 CS15 MAGI-Based Incorporated within Income a separate subsection Methodologies under section 4.3 MI-13-0002 XXI Medicaid | CS3 Eligibility for Supersedes the Expansion Medicaid Expansion } current Medicaid Date Submitted: Program expansion section 12/20/13 4.0 Approval Date: 12/22/14 Effective/Implemen tation Date: January 1, 2014 MI-13-0003 Establish CS14 Children Ineligible | Incorporated within 2101(f) Group for Medicaid as a a separate subsection Date Submitted: Result of the under section 4.1 12/20/13 Elimination of Approval Date: Income Disregards 03/17/14 Effective/Implemen tation Date: January 1, 2014 MI-13-0004 Eligibility CS24 MAGI-Based Supersedes the Processing Eligibility Process current items in Date Submitted: sections 4.3 and 4.4 12/20/13 related to application Approval Date: processing, 03/11/14 eligibility screening Effective/Implemen and enrollment, and tation Date: renewals

Effective Date: January 1, 2019

Approval Date: October 10, 2019

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

Transmittal SPA Group PDF # Description Superseded Plan Number Section(s) October 1, 2013 MI-13-0005 Non-Financial |CS17 | Non-Financial Supersedes the Eligibility Eligibility — current section 4.1.5 Date Submitted: Residency 12/20/13 Supersedes the Approval Date: CS18 | Non-Financial current section 4.1.0 12/17/15 Eligibility — Effective/Implemen Citizenship tation Date: Supersedes the January 1, 2014 €S19 Non-Financial current section 4.1.9 Eligibility — Social Security Number Effective/Implemen tation Date for CS20 | Non-Financial Supersedes the CS20 only: Eligibility — current section 4.4.4 January 24, 2014 Substitution of Coverage Cs21 Non-Financial Supersedes the Eligibility — current Cost Sharing Non-Payment of and Payment section Premiums 8.7 MI-15-0003 XXI Medicaid | CS3 Eligibility for Supersedes the Expansion Medicaid Expansion | current Medicaid Date Submitted: Program expansion section 12/17/15 4.0 and MI-13-0002 Approval Date: 03/08/16 Effective/Implemen tation Date: January 1, 2016 MI-15-0004 Non-Financial | CS21 Non-Financial Supersedes the Eligibility Eligibility — current Cost Sharing Date Submitted: Non-Payment of and Payment section 12/17/15 Premiums 8.7

Effective Date: January 1, 2019

Approval Date: October 10, 2019

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 8 Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) Approval Date: 03/08/16 Effective/Implemen tation Date: January 1, 2016

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

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

State Response: Much attention has been given to the problem of the lack of health insurance coverage for the unborn child in low-income families whose incomes are at or below 195 percent of the Federal Poverty Level and who are uninsured. This is the baseline figure used by Michigan as the target for Medicaid or Maternity Outpatient Medical Services (MOMS) enrollment.

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

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

State Response: Michigan currently has several programs focused on identifying potentially eligible Medicaid clients and assisting them to complete enrollment forms to become Medicaid recipients. All local health departments in the state have at least two sources of funding specifically for outreach to families and children not currently enrolled in Medicaid and for provision of assistance in applying for Medicaid eligibility.

Medicaid provides funding to all forty-two local health departments so they can identify pregnant women whose unborn child is not currently enrolled in Medicaid, assist them in completing enrollment materials, and in selecting and obtaining access to health care providers serving Medicaid eligible pregnant women and the unborn child. The health departments also have a Prenatal Care Enrollment and Coordination Program which provides outreach to facilitate access

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 9 to prenatal care through the Healthy Kids Program, and assistance in obtaining access to a prenatal care provider. This program also provides families with assistance in completing Medicaid enrollment forms for children, which are then forwarded to Medicaid for determination of eligibility. Services provided through this program include assistance in completion of the, Medicaid application gathering all required verifications, negotiating the Medicaid system, obtaining health care providers, responding to managed care problems/concerns, and obtaining access to other support programs.

Several other programs provide outreach for special populations as identified below.

• Maternal Support Services (MSS): Pregnant women and teens that are potentially Medicaid-eligible are assisted in obtaining Medicaid enrollment by providers throughout the state. As with the ISS program, both public and private agencies are providers. This program also provides services to non-Medicaid-eligible women and teens with additional state funding made available for this purpose.

•

Maternal and Infant Health Advocacy Services Program (MIHAS): This program provides outreach to pregnant women who are not currently receiving prenatal care, assists them in dealing with situations which may keep them from remaining in prenatal care, and supports and reinforces the health education messages delivered by health care providers. MIHAS services are delivered by a team of paraprofessional advocates and a supervisor specifically trained to deal with the psychosocial problems of high-risk, low- income pregnant women. Paraprofessional advocates must be indigenous to the community and have been on Medicaid.

•

Special Supplemental Nutrition Program for Women, Infants and Children (WIC): WIC screens and refers clients to other appropriate health and social services, including Medicaid, food stamps, prenatal care, immunizations, smoking cessation programs, and substance abuse programs. Referral of WIC clients for Medicaid enrollment is a required outreach activity in this program. Nearly half of the infants born in Michigan are served by the WIC Program, making this an important source of outreach for Medicaid enrollment.

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

State Response: Prenatal Care Enrollment and Coordination Program provides outreach to facilitate access to prenatal care and assistance in obtaining access to a prenatal care provider. Michigan is working with Covering Kids, a national public/private partnership, by providing staffing and materials to promote education and outreach at health-related conferences. The

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 10 Michigan initiative is called Covering Michigan’s Kids.

NOTE: In the revised “Template for Child Health Plan under title XXI of the Social Security Act Children’s Health Insurance Program,” section 2.2 is designed specifically for states to request to use the funds available under the 10 percent limit on administrative expenditures to implement a health services initiative. The revised section 2.2 reads as follows:

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

As permitted under section 2105(a)(1)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, the State of Michigan is doing a health services initiative that will use CHIP funds, within the federal administrative expenditures cap allowed for states, to support the Michigan Poison Control Center (MPCC) at Wayne State University. Effective August 1, 2019, the MPCC administration will transition from Children’s Hospital of Michigan to Wayne State University. Separate payments will be made to each entity based on the periods of administration. The MPCC provides emergency telephone treatment advice, referral assistance, and information to manage exposures to poisonous and hazardous substances. The MPCC answers poisoning emergency calls from the general public as well as health care providers needing assistance 24 hours a day, 365 days each year at no charge to the caller.

The MPCC provides numerous services including:

• 24-hour emergency and information hotline services • follow-up calls regarding continuing care in poison exposure cases • health and safety professional education • state and national data collection providing epidemiologic public health surveillance • access to emergency information as an integral part of local, state and national emergency preparedness • responses for natural and manmade disasters • acting as a clearinghouse for scarce resources and antidotes • providing guidance in the treatment of hazardous incidents to the public • providing interpretative assistance of forensic data for law enforcement and medical examiners • assisting other federal and state agencies in risk-assessment for potentially toxic exposures

Certified Specialists in Poison Information and medical or clinical toxicologists are available 24 hours a day, 365 days a year to manage cases. The service is provided via a toll-free telephone

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 11 number to every community throughout Michigan, including under-served, low income, and indigent populations. Services are available by use of an interpreter in over 150 languages and via telecommunications devices for the deaf and hearing impaired (TTY).

The MPCC provides public education programs directed towards pediatric accidental poisoning as well as targeted “at-risk” populations. Educational materials and teaching curricula are distributed throughout the state, free of charge to the public. Materials are also available in Spanish and Arabic. The MPCC participates in a variety of community injury prevention including health fairs. The MPCC also provides a robust professional educational program designed to train medical and safety professionals in the identification and treatment of poisoning and hazardous exposures including pre-hospital and first-responder training.

The MPCC receives approximately 64,000 calls annually involving individuals exposed to poisons or hazardous substances. Sixty percent of all poisoning exposure calls received involve children under age 19. For CHIP eligible children, over 33 percent of the total calls relate to poisoning exposures of children in families whose annual household incomes is $51,500 or less (200% FPL for a family of 4 in 2019). In addition to calls regarding exposures, the MPCC receives over 10,000 calls each year from callers requesting information about poison prevention, effective use of chemicals, drug identification, substance abuse and other medical questions. These calls are considered preventive.

MPCC intervention resulted in over 71 percent of the unintentional exposure calls (in children under age 19) being handled in the home so the children did not have to use an emergency department or need a 911 call and response. For those children whose exposure necessitated hospital evaluation and treatment, MPCC intervention contributed substantially to reduced resource utilization and decreased length of stay with significant cost savings to the community.

The state assures that the Michigan Poison Control Center (MPCC) at Wayne State University will not supplant or match CHIP federal funds with other federal funds, nor allow other federal funds to supplant or match CHIP federal funds.

As permitted under section 2105(a)(1)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, the State of Michigan is doing a health services initiative that will use CHIP funds, within the federal administrative expenditures cap allowed for states, to support expanded lead abatement activities in the impacted areas of Flint, Michigan and other areas within the State of Michigan, as further described herein. Federal assistance is necessary to minimize and further prevent any long-term adverse health effects associated with lead exposure, both in Flint and across Michigan. This targeted and time-limited health services initiative would complement other federal, state and local efforts to abate lead hazards from the homes and improve the health of Medicaid and CHIP eligible individuals.

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

As alluded to in Michigan’s February 14, 2016 application for the now approved Section 1115 Demonstration, the State is seeking federal funding pursuant to Section 2105(a)(1)(D)(ii) of the Social Security Act for the enhancement and expansion of its current lead abatement program through the use of a CHIP health services initiative. As part of this expansion, the State would provide coordinated and targeted lead abatement services to eligible properties in the impacted area to mitigate all lead risks to the extent possible up to the point of family and/or property owner disengagement. Abatement services are defined as the removal of lead hazards, including:

e The permanent removal, or enclosure, or encapsulation of lead based paint and lead dust hazards from an eligible residence.

e The removal and replacement of surfaces or fixtures within the eligible residence. e The removal or covering of soil lead hazards up to the eligible residence property line.

e Minimal rehab to the extent that this work helps to extend the life of the lead abatement work done consistent with HUD guidelines (located at https://www.hud.gov/offices/lead/library/lead/PGI-2008-02 Doing Minimal Rehab.pdf) and any subsequent amendments to the HUD guidelines, and

e All preparation, lab sampling analysis, clean up, disposal, and pre and post-abatement paint, dust, soil and clearance testing activities associated with such measures including pre and post-water sampling.

Eligible properties include owner-occupied, rental, and residential structures that an eligible individual inhabits or visits regularly (e.g. home of a family member, relative, or other informal child care where a child often visits). A rental property funding scale for those with ownership stake in more than 1 rental property may be established to reduce the CHIP HSI federal and state program spending on the related projects and maximize the number of homes in which the program provides abatement assistance and to ensure that the program is able to enroll high cost projects in the program equitably among property owners. Project cost must be approved by Regional Field Consultant to align with estimate and Healthy Homes Section Manager. There is currently no maximum funding cap placed on rental unit projects however, rental property owners may be asked to provide match to the project as follows:

Number of Units | Maximum Assistance Provided PER UNIT, by LSHP- Based on number of units Owned by RPO, enrolled

in addition to enrolled unit (s)

Single Family Unit 2-4 Units Adjoined >5 units Adjoined 1 100%

2-4 95% 85% 75% >5 80% 70% 60% Effective Date: January 1, 2019 Approval Date: October 10, 2019

12

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 13

Once work has started on an eligible property, all eligible surfaces and fixtures will be abated to the extent possible up to the point of family and/or property owner disengagement. A client engagement protocol is being implemented by the state to maximize participation. Eligible surfaces for abatement activities include all structural components identified during an environmental investigation or the lead inspection/risk assessment as hazards including but not limited to: all window components, door and door frames, stairs, interior walls and ceilings, painted cabinets, interior railings, painted floors, exterior porches, exterior painted siding, exterior windows and trim, exterior trim boards, exterior painted siding, trim and doors on garages and other structures, and soil. Eligible fixtures includes all interior plumbing components with the general exception of the interior water meter, which will be addressed in accordance with each community’s coordinated plan. In Flint, this also includes the exterior lead and galvanized steel service lines that supply drinking water to the home, which shall be completed concurrently or prior to abatement of interior plumbing fixtures funded through this initiative. Outside of Flint, the State will recommend replacement of faucets that have not been replaced prior to 2014 regardless of water sample result, and fixture and/or complete lead and galvanized steel service line replacement if water sampling results are above the acceptable level. A home shall not be deemed abated if water results indicate the presence of lead in the water supply line over the acceptable level.

The state assures that no partial service line replacements will be conducted under this health services initiative. Service line replacement must be “complete,” meaning that both the public and private portions of the service line will be replaced. The state will supplement, not supplant, other federal, state, and local funds allocated for the removal of service lines. For the purposes of this request, abatement does not include any of the following:

• Work that does not reduce a lead hazard.

• Work not performed by a certified lead abatement professional and/or a licensed plumber

• Work that is not the responsibility of the property owner or landlord outside the confines of the property lines, with the exception of the public portion of service lines in Flint and on a case by case basis in other communities following the guidelines put forth in this health services initiative.

• Work on dwellings that have not been determined at application to have an eligible Medicaid or CHIP individual, under the age of 19, or pregnant women residing or frequently visiting the structure.

Provision of Abatement Services

For this health services initiative, abatement activities would only be permissible for federal funds if the services are delivered to properties that have been determined at application to have a Medicaid or

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 14 CHIP-eligible individual, under the age of 19, or pregnant woman residing or visiting regularly. Services may be rendered to the physical structure and include the surrounding land up to the property line, and would be coordinated with any service line removal that occurs outside of the property line. Federal funds can be used to support family relocation costs for up to 10 days if needed consistent with HUD guidelines and any subsequent amendments to the HUD guidelines. This limit on relocation day support can be extended on a case by case basis. This SPA will be in effect for five years from the effective date or until all homes included in the scope of this SPA have been abated for lead.

The State will ensure that eligible properties in the impacted areas of Flint, Michigan receive priority status. Upon approval of this health services initiative, outreach will begin to identify eligible properties and engage affected beneficiaries in Flint. The State will concurrently begin identifying other high-risk communities within Michigan that will be targeted for health services initiative- approved abatement activities. Target communities will be selected based on the following criteria: • Number/percentage of population under age 6 with an elevated blood lead level of ≥ 5 ug/dL; • Percentage of population that is low-income; • Number/percentage of pre-1978 and pre-1940 housing stock; and • Other social determinant factors (e.g. unemployment rate, number/percentage of children receiving state assistance and housing conditions).

Medicaid or CHIP-eligible beneficiaries that have a blood lead level ≥ 5 ug/dL in non-target areas will also be eligible for abatement activities.

In Flint, abatement services on eligible properties must be coordinated with the ongoing state and local water service line efforts. Interior plumbing and fixture abatement will be done only after service line replacement, if required under this health service initiative, has been completed. In Flint, interior plumbing and fixture abatement may occur prior to service line replacement if the city of Flint is handling the replacement of the service line. In such circumstances, after the replacement of the service line is complete, a whole house flushing procedure that will include allowing the water to flush through the plumbing, removing and cleaning aerators or replacing them if necessary, and testing of water samples to ensure no recontamination of the interior plumbing and fixtures must be performed.

Prior to starting work on homes in additional target areas, the State will notify CMS 60 days prior to work beginning in those communities. Additionally, the State will work with each community to develop a coordinated plan to guide these lead abatement activities. Services performed must be part of a comprehensive plan that ensures abatement activities of the eligible individual’s residence align with the affected infrastructure needs (if applicable).

Individuals performing abatement services must be properly certified by the state. Only a person certified by MDHHS as a lead abatement supervisor or lead abatement worker may perform lead abatement activities in accordance with state law. A supervisor is defined as an individual who has been trained by an accredited training program and certified by MDHHS to supervise and conduct lead abatement services and to prepare occupant protection plans and abatement reports. A lead

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 15 abatement supervisor is required for each lead abatement job, and must be present at the job site while all abatement work is being done. This requirement includes set up and clean up time. The lead abatement supervisor must ensure that all abatement work is done within the limits of federal, state, and local laws.

A lead abatement worker is an individual who has been trained to perform abatements by an accredited training program and who is certified by MDHHS to perform lead abatement. Professionals certified by MDHHS are issued a card containing the person’s picture, name, certification number, and expiration date. All certified professionals must work for a MDHHS certified lead abatement company. The abatement company and its employees must use abatement methods approved by the U.S. Department of Housing and Urban Development (HUD) and/or the U.S. Environmental Protection Agency (EPA) and in accordance with state laws and regulations.

The department may certify entities who meet the professional requirements for lead and galvanized steel service line removal and have been contracted to do such work under an approved coordinated plan.

For the purposes of this health services initiative, MDHHS requests funding to supplement the training of individuals in lead abatement in accordance with Michigan Compiled Law 333.5461 – 333.5468. Individual training for certification/licensure must occur through an accredited training program specific to lead. These funds will ensure that access to appropriate levels of lead professionals are available to mitigate lead risks in a timely manner.

Lastly, MDHHS requests funding to supplement the administrative functions necessary to successfully implement this CHIP health services initiative. The funding received for this request will supplement but not supplant other federal funding sources for lead abatement or the training/credentialing process of inspectors.

Post-Abatement Activities

MDHHS recognizes that abatement activities would only be eligible for federal assistance when performance of these activities can be demonstrated to be effective in abating all identified lead hazards and extending the life of the related abatement activities. State and federal laws dictate that a clearance test must be performed after any lead abatement work is finished to verify the work area is safe enough for the eligible resident(s) to return. On the inside of a house or apartment the dust is tested to confirm that abatement work has not created lead dust hazards that can poison young children, other occupants, or pets living in the building as defined in state law. Water sampling will also be conducted to confirm that respective plumbing component replacement has successfully reduced lead levels in the drinking water of affected homes.

Only a certified lead inspector or risk assessor, who is independent of the abatement company, may perform clearance testing after abatement work is completed. A certified inspector is defined as an individual who has been trained by an accredited training program and certified by MDHHS to

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 16 conduct inspections and take samples for the presence of lead in paint, dust and soil for the purpose of abatement clearance testing. A certified risk assessor is defined as an individual who has been trained by an accredited training program and certified by MDHHS to conduct inspections and risk assessments and to take samples for the presence of lead in paint, dust and soil for the purpose of abatement clearance testing.

During the clearance testing, an interior visual inspection is done to see if the identified lead hazards have been abated. These professionals also inspect for the presence of any visible dust or paint chips. If any problems are found the abatement supervisor must resolve all of them before the clearance testing may continue. After the visual inspection passes, the lead inspector or risk assessor must take dust wipe samples that are sent to a lab for analysis. Clearance dust samples must be taken from the floors, windowsills, and window troughs in the rooms where work was done. At least one sample must be taken from outside the work area if containment was used and from each unique passage way. If no containment was used, then dust wipe samples may be taken in any room. A floor and a window in at least four rooms must be sampled. The samples must be tested for lead by an EPA approved lab. After exterior paint abatement work is completed, an Inspector or Risk Assessor must perform a visual inspection of the outdoor work area ensure that the lead hazards were properly addressed. The lead inspector or lead risk assessor will then look for any paint chips on the ground including the foundation of the house, garage, or below any exterior surface abated. If paint chips are present, the abatement company must remove the chips and debris from the site and properly dispose of them before the clearance can be finished. No dust wipe clearance testing is required for abatement on the exterior of a house or rental property.

Water sampling protocols will follow prescribed methodology required in the EPA Lead and Copper rule.

Metrics/Reporting Requirements

The state believes that this health services initiative will abate identified lead hazards from the homes and improve the health of Medicaid and CHIP eligible individuals, both in Flint and throughout Michigan. Providing for enhancement and expansion of the lead hazard removal program will reduce the potential for ongoing exposure or re-exposure to lead hazards for the eligible population and future populations. A publicly-available housing registry of these ameliorated properties will be maintained by the state.

Key Metrics the state will track and report to CMS monthly or at another approved interval include:

• Number of houses identified with high levels of lead hazards in each of the targeted area(s)

• The number of homes in each of the targeted areas scheduled for lead hazard abatement.

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 17 • The number of homes in each of the targeted areas in which lead hazard abatement has occurred.

 Number of houses abated for pregnant women.

 Number of houses abated for CHIP or Medicaid children under the age of 19.

• Record of actual services provided in each house.

• Clearance testing results.

• Percentage of children receiving blood lead testing under EPSDT statewide and in the areas targeted by this health services initiative.

• Percentage of children with elevated blood lead levels statewide and in the areas by this health services initiative.

Other metrics may be added at the agreement of the state and CMS during implementation of the HSI.

The results of the clearance testing will be maintained by the state. These testing results will have numbers with units of measurement; the units are different for dust and soil. EPA and HUD regulations define clearance lead levels with the values and units of measurement shown in the table below.

Material Tested Considered hazardous if lead is present at or above these levels* Bare soil (child play areas) At or above 400 parts per million (ppm) of lead in the soil Bare soil (other areas) At or above 1200 ppm of lead Water

Equal to or more than 15 parts per billion (ppb) of lead in water House dust (floors)

At or above 40 micrograms of lead per square foot of sampled area (ug/ft2) House dust (window sills) At or above 250 ug/ft2 of lead House dust (window troughs)

At or above 400 ug/ft2 of lead Paint tested by an X-Ray Fluorescence (XRF) analyzer

equal to or more than 1.0 milligrams per square centimeter (mg/cm2) of lead on a deteriorated sampled surface or an elevated dust wipe sample corresponding to the lead surface Paint tested by paint chip analysis

equal to or more than 0.5% (one half of 1 percent) lead by dry weight, or equal to or more than 5,000 parts per million of lead in paint (ppm) * All levels indicated in the table above will be utilized until and unless more stringent

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 18 guidelines are promulgated at the state or federal level.

The state assures that this health services initiative will not supplant or match CHIP federal funds with other federal funds, nor allow other federal funds to supplant or match CHIP federal funds.

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

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

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

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State.

No, the State does not use a managed care delivery system for any CHIP populations.

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 19

Yes, the State uses a managed care delivery system for all CHIP populations.

Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee-for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2.

Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 20 2102(a)(4); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations.

State Response: Medical services for the unborn child will be provided on a fee-for- service basis. All pregnancy-related services must be determined to be medically necessary. Medical service coverage for unborn children is limited to the following prenatal and pregnancy- related services:

• Prenatal Care • Maternal Support Services (MSS) • Note: Pre-pregnancy family services and supplies are not covered for unborn children, • Labor and delivery: Professional services fee, including live birth, miscarriage, ectopic pregnancy, and stillborn. • Radiology and ultrasound • Childbirth education • Laboratory • Pharmaceuticals and prescription vitamins • Inpatient Hospital for Delivery Only • Outpatient Hospital • Note: Outpatient deliveries are not covered.

MDHHS , which includes public health, mental health and Medicaid, is committed to the development and implementation of community-based collaborative efforts to assist the pregnant woman and her unborn child Multipurpose Collaborative Bodies have been established throughout the state and are charged with community-based planning and service provision. These collaborative bodies include public and private agencies and organizations focused on prenatal care for all unborn children.

The program developed under Title XXI will utilize the current networks described above to publicize the availability of prenatal coordinate activities that include assisting pregnant women and the unborn child and utilize various transportation, interpreter and other support services to enhance access to health care providers.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 21 and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

State Response: The State anticipates a capitation methodology of payment. The State will use its actuarial contractor to establish appropriate rates.

With a risk-based model, the state’s oversight focus will be concentrated on ensuring that needed, quality services are received rather than focusing on issues attendant to service over-use. If the medical services reimbursement mechanism is non risk-based, the State will be equally sensitive to possibilities of service over-use and concerns of accessibility and quality of services received.

Utilization controls/reviews are detailed extensively after Section 7.1 after the heading “State Oversight and Monitoring.”

Federally Qualified Health Center (FQHC) and Rural Health Center (RHC)

Section 503 of CHIPRA amends section 2107(e) (l) of the Act to make section 1902(bb) of the Act applicable to CHIP in the same manner as it applies to Medicaid. Section 1902(bb) governs payment for Federally Qualified Health Centers (FQHC's) and Rural Health Clinics (RHC's).

FQHC's and RHC's will be reimbursed based on the Medicaid Prospective Payment System (PPS). PPS was enacted into law under section 702 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000. Under the PPS, FQHC's and RHC's will be reimbursed on a per visit basis. The per visit payment is the Medicaid State plan PPS rate, effective for services provided on or after October 1, 2009. Reasonable costs are defined as the per visit amount approved by Medicare as adjusted to reflect the cost of providing services to CHIP beneficiaries that are not covered by Medicare – i.e. dental services, on-site laboratory and x-ray, non-emergency transportation, and outreach.

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 22 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

*Policy narrative is superseded by forms listed in roster 1.4

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

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

4.1.1. X Geographic area served by the Plan: Statewide

4.1.2 Age: conception through birth

4.1.3. X Income: at or below 195% percent of the federal poverty level For children from conception through birth, the adjusted gross income is 0 to 195% of the federal poverty level (FPL).

4.1.4 X Resources (including any standards relating to spend downs and disposition of resources): No resource test

4.1.5. X Residency (so long as residency requirement is not based on length of time in state) : Must be a resident of Michigan or be in Michigan to seek employment.

4.1.6. ∼ Disability Status (so long as any standard relating to disability status does not restrict eligibility): None

4.1.7. X Access to or coverage under other health coverage State Response: Comprehensive employer-based coverage by other creditable health insurance will preclude enrollment in this program

4.1.8. X Duration of eligibility:

State Response: Eligibility continues from the date of application through two months post partum.

4.1.9 Other standards (identify and describe): Applicants are required to provide a Social Security Number or they must have applied for SSN. Not required of others.

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

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

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Approval Date: October 10, 2019 23

4.2.1. X These standards do not discriminate on the basis of diagnosis. 4.2.2. X Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3. X These standards do not deny eligibility based on a child having a pre- existing medical condition.

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

State Response: The following process will be used to determine eligibility and continued enrollment:

. ENROLLMENT PROCESS

• receive completed applications and any required verifications,

• determine initial eligibility based on information presented,

.

BEGIN DATE OF ENROLLMENT

Eligibility begins on the first day of the month of application with retroactive coverage to the date of pregnancy up to 3 months prior to the applications date..

ELIGIBILITY CRITERIA

In order to be eligible for coverage for the unborn child • The unborn child must be a resident of Michigan, • Must reside in a family with an adjusted gross income of less than or equal to 195 percent of poverty No asset test is used. The income will be verified by self-declaration.

• The pregnant woman of the unborn child must have no comprehensive employer-based insurance coverage. Coverage through the CSHCS program and the Indian Health Services is not to be considered as other insurance for eligibility purposes.

QUALITY ASSURANCE/MONITORING

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b)) X Check here if this section does not apply to your state.

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 24 4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic re-determination, that only targeted low- income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

State Response: The State will perform post-eligibility audits of the applications to assure compliance with eligibility and enrollment policies. In addition, part of the quality assurance methodology will be planned reports on the following:

• list of enrollees by county (this will be compared to the Medicaid population to assure the enrollee is not receiving both Medicaid and non-Medicaid CHIP (Maternity Outpatient Medical Services (MOMS) • number of applications received

• number of denials of applications with the reasons for denial

• corrective actions, regarding program compliance (e.g., presumptive eligibility)

Application reviews will include assurance that any required verifications have been used, time frames have been met, and appropriate referrals have been made.

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

State Response: Department staff will determine if the child is Medicaid

If the Department determines the unborn child to be Medicaid eligible, the unborn child will NOT be enrolled in the MOMS. If the Department determines the unborn child to be ineligible for Medicaid they will have eligibility determined for MOMS.

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

If the Department determines the unborn child to be Medicaid ineligible, the application will be reviewed at that time to determine eligibility in MOMS

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

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Approval Date: October 10, 2019 25

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

4.4.4.1. x Coverage provided to children in families at or below 195 % FPL: describe the methods of monitoring substitution.

State Response: The application form will include a request for information regarding other insurance coverage. Pregnant women who have creditable employer based health coverage which provides prenatal services to the unborn child will not be enrolled in MOMS. 4.4.4.2.  Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

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

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

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

The minimum employer contribution.

The cost-effectiveness determination.

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

State Response: Outreach efforts will include the Indian Health Centers and other agencies providing services to Native Americans.

The application form also indicates the American Indian ethnicity in its demographic information requested. Submitting this information is voluntary. Targeted outreach may be initiated if necessary.

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 26

Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

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

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

6.1.1 Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

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

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

6.1.4. X Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1. Coverage the same as Medicaid State plan

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

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Approval Date: October 10, 2019 27 6.1.4.2.  Comprehensive coverage for children under a Medicaid Section 1115 demonstration project

6.1.4.3.  Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4.  Coverage that includes benchmark coverage plus additional coverage 6.1.4.5.  Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6.  Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. X Other (Describe) Coverage to unborn children Medical services for the unborn child will be provided on a fee-for- service basis. All pregnancy-related services must be determined to be medically necessary. Medical service coverage for unborn children is limited to the following prenatal and pregnancy- related services:

• Prenatal Care • Maternal Support Services (MSS) • Note: Pre-pregnancy family services and supplies are not covered for unborn children, • Labor and delivery: Professional services fee, including live birth, miscarriage, ectopic pregnancy, and stillborn. • Radiology and ultrasound • Childbirth education • Laboratory • Pharmaceuticals and prescription vitamins • Inpatient Hospital for Delivery Only • Outpatient Hospital • Note: Outpatient deliveries are not covered.

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

6.2.1. Inpatient services (Section 2110(a)(1)) 6.2.2 . Outpatient services (Section 2110(a)(2)) 6.2.3. Physician services (Section 2110(a)(3)) 6.2.4. Surgical services (Section 2110(a)(4))

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 28 6.2.5. Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6. Prescription drugs (Section 2110(a)(6)) 6.2.7. ∼ Over-the-counter medications (Section 2110(a)(7)) 6.2.8 Laboratory and radiological services (Section 2110(a)(8)) 6.2.9. X Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 6.2.10 Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11. Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) 6.2.12. Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13. Disposable medical supplies (Section 2110(a)(13)) 6.2.14. ∼ Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15. Nursing care services (See instructions) (Section 2110(a)(15))

6.2.16. Abortion only if necessary to save the life of the mother (Section 2110(a)(16) 6.2.17 Dental services (Section 2110(a)(17)) 6.2.18 Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19 Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20. Case management services (Section 2110(a)(20)) 6.2.21 Care coordination services (Section 2110(a)(21)) 6.2.22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23. Hospice care (Section 2110(a)(23)) 6.2.24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25. ∼ Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26. Medical transportation (Section 2110(a)(26)) 6.2.27. ∼ Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28. ∼ Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 29 6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes No Guidance: If the State does not provide any mental health or substance use disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)). Continue on to Section 6.3.

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

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 30 6.3.1. X The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2. ∼ The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre- existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010)

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

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

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

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

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 31 6.4.2. ∼ Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a)) 6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3. The state assures that the coverage for the family otherwise

meets title XXI requirements. (42CFR 457.1010(c))

Section 7. Quality and Appropriateness of Care

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

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

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1. Ξ Quality standards 7.1.2. Ξ Performance measurement 7.1.3. Ξ Information strategies 7.1.4. Ξ Quality improvement strategies

State Response: The State plans to assure the quality and appropriateness of care, particularly with respect to prenatal care and labor and delivery of the unborn child. Health Maintenance Organizations (Public Act 1978, No. 368 or Michigan Compiled Laws 333.21001)

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

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 32 457.495)

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

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

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

State Response:

Section 8. Cost Sharing and Payment (Section 2103(e))

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

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

8.1.1. YES 8.1.2. X NO, skip to question 8.8.

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

8.2.1. Premiums:

8.2.2. Deductibles:

State Response: Michigan will assess no deductibles.

8.2.3. Coinsurance or co-payments:

8.2.4. Other: None

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 33 8.3. Describe how the public will be notified, including the public schedule, of this cost- sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

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

8.4.1. Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2. No cost-sharing applies to well-baby and well-child care, including age- appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3 No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

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

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

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

8.7.1 Please provide an assurance that the following disenrollment protections are being applied to all enrollees: 8.8 The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.  No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.  No cost-sharing (including premiums, deductibles, co-pays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3. X No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1))

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019 34 8.8.4. X Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5.  No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother. (Section 2105)(c)(7)(B)) (42CFR 457.475)

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

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019

35 Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

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

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

State Response:

Goal 1. Continue to enroll the uninsured, low income pregnant women and their unborn child in Michigan in either the Medicaid program or MOMS, as appropriate.

Goal 2. Obtain accurate, usable HEDIS or HEDIS-like reports from providers and monitor the following outcomes with emphasis on:

Prenatal Care for the unborn child

Goal 3. Local agencies and programs will contact pregnant women and advise them of the prenatal care available to their unborn child through Medicaid and MOMS.. Goal 4. Provide an application and enrollment process which is easy to understand and use.

Goal 5. Obtain the participation of community-based organizations in outreach and education activities.

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

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4)) 9.3.1.  The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.  The reduction in the percentage of uninsured children. 9.3.3.  The increase in the percentage of children with a usual source of care. 9.3.4.  The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.  HEDIS Measurement Set relevant to children and adolescents younger than 19.

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019

36 9.3.6.  Other child appropriate measurement set. List or describe the set used.

9.3.7.  If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1.  Immunizations 9.3.7.2.  Well child care 9.3.7.3.  Adolescent well visits 9.3.7.4.  Satisfaction with care 9.3.7.5.  Mental health 9.3.7.6.  Dental care 9.3.7.7.  Other, please list: 9.3.8.  Performance measures for special targeted populations. 9.4.  The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

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

State Response: The Michigan Department of Health and Human Services will perform the annual assessments and evaluations required in Section 2108 (a). The annual report will include an assessment of the MIChild Plan and its progress toward meeting its strategic objectives and performance goals.

Beginning March 31, 2000, the State will submit an annual evaluation that includes the following elements as specified in Section 2108 (b).

The State will submit a description and analysis of the effectiveness of the elements of the State plan, including:

Demographics: The demographic characteristics of the unborn children assisted under the State plan will be identified

1. Quality: The quality of health coverage provided including the types of benefits provided. The State will measure quality as described in Section 7.1 and 7.2. Effectiveness will be determined by the extent to which strategic objective performance goals are met.

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019

37 Service area: The State offers coverage on a statewide basis.

The Department of Health and Human Services will analyze changes and trends in the State that affect the provision of accessible, affordable, quality health insurance and health care to the unborn child 9.6.  The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

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

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

9.8.1.  Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.  Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.  Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.  Section 1132 (relating to periods within which claims must be filed)

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

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

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

State Response

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019

38 9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

 Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment.  Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

MIChild Budget Assumptions

Budget Neutrality. The assumption is that the program will remain budget neutral.

Payments to Benefit Contractors. Premiums for health, vision, and dental coverage are estimated to be $90 per month. Enrollment in MIChild during FY 15 reached 44,508 children by midyear. Average monthly enrollment for FY 15 was 42,460 children. For FY 2016 and beyond, the state hopes to achieve enrollment of 90 percent of the total number of eligible children. Average monthly enrollment in the MIChild /Medicaid expansion is estimated to be 40,000 children for FY 2016 and beyond. The program will provide Medicaid services to children using managed care and fee for service.

Mental Health and Substance Abuse Services. Mental health and substance abuse services are Medicaid covered services. All services are provided in accordance with Medicaid

Administrative Oversight. Administration of the program will be conducted by the Single State Agency with regard to eligibility determination and implementation of Medicaid policy. The Single State Agency will employ an outside contractor to collect monthly premium payments for this program. The contractor will notify Agency of any delay in premium payment or failure to pay a premium. The contractor will also perform enrollments (now voluntary and auto-assignments) into health plans, provide education regarding services, perform mailings which now also include MIHealth cards.

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019

39

This reporting period: Federal Fiscal Year 2019. This is a combination budget.

COST OF APPROVED SCHIP PLAN

COST OF APPROVED CHIP PLAN 2019 Baseline 2019 with SPA 18-0020 Insurance Payments

Managed Care 236,697,988 236,697,988 Fee for Service 38,138,890 38,138,890 Total Benefit Costs 274,836,878 274,836,878 (Offsetting beneficiary cost sharing payments) - - Net Benefit Costs 274,836,878 274,836,878

Administration Costs Personnel

General Administration 1,130,000 1,130,000 Contractors/Brokers (e.g., enrollment contractors) 360,000 360,000 Claims Processing

Outreach/Marketing costs

Other (e.g., indirect costs)

Health Services Initiatives 23,306,000 23,306,000 Total Administration Costs 24,796,000 24,796,000 10% Administrative Cap (net benefit costs divided by 9) 30,537,431 30,537,431

Federal Title XXI Share 293,999,780 293,999,780 State Share 5,633,098 5,633,098

TOTAL COSTS OF APPROVED CHIP PLAN 299,632,878 299,632,878

Non-Federal source of funding: State Appropriations (General Fund)

Note that in future years, the intent is to maximize the use of funds available under the administrative cap to the extent possible to support lead abatement efforts as outlined in the Health Services Initiative Section.

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019

40 Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750) 10.1.1.  The progress made in reducing the number of uncovered low-income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment,

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

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

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019

41

Section 11. Program Integrity (Section 2101(a))

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

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

State Response

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1.  42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.  Section 1124 (relating to disclosure of ownership and related information) 11.2.3.  Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.  Section 1128A (relating to civil monetary penalties) 11.2.5.  Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.  Section 1128E (relating to the National health care fraud and abuse data collection program)

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019

42 Section 12. Applicant and enrollee protections (Sections 2101(a))

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

Eligibility and Enrollment Matters

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

State Response: Eligibility and Enrollment issues are addressed in detail in Section 4. The Department maintains a website where the public may either download and print an application to submit, or may elect to file the electronic application available at this web site. Submitting an electronic application yields an immediate decision and is the most efficient means of expediting an application. If a person does not have online access, they may be assisted at a local health department in having the information entered for them.

The state provides opportunities and imposes standards for review of eligibility and enrollment decisions in accordance with 42 CFR 457.1120 – 42 CFR 457.1180.

Each applicant/enrollee is provided with the necessary request forms allowing them to challenge decisions regarding: l) The denial of eligibility 2) Failure to make a timely determination of eligibility 3) Suspension or termination of enrollment The review request forms are sent to the applicant/enrollee at the same time as the notification of the denial/termination decisions. The review request forms include directions for completing the review request form, the mailing address for submitting the review request and a toll-free phone number for assistance in completing the review request form.

The State ensures that the applicant/enrollees in the medical programs receive impartial reviews of all matters pertaining to eligibility/enrollment by referring requests for reviews of the action taken to persons not directly involved in the matter under review. Representatives of the Department of Health and Human Services conduct the formal review of the actions. Neither department representative has been directly involved in the disputed action/decision under review. The Quality Assurance Analyst with the Department of Health and Human Services reviews the action taken determines if actions were in compliance with the stated policy. The analyst then presents their findings to the Department of Health and Human Services Hearings Officer. The hearings officer determines if the denial/termination should be upheld or overturned based on the findings of the analyst. The applicant/enrollee is then notified of the decision.

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

Effective Date: January 1, 2019

Approval Date: October 10, 2019

43

In matters of Medicaid eligibility/enrollment, terminations of Medicaid are suspended if the request for review is received prior to the termination date. The applicant/enrollee continues to receive Medicaid until the decision is rendered by the Administrative Law Judge. There is no cost sharing involved with the Medicaid programs.

Enrollees/applicants are given timely written notice of any denial/termination of eligibility. The notification includes the reason for the determination, an explanation of the applicant’s rights to review of the decision, the standard and expedited time frames for requesting a review. The applicant/enrollee is also advised of their right to review a decision and provided with instruction on how to request a review and how to continue current eligibility while the review is pending along with a contact phone number (including a number for individuals with hearing and speech difficulties) to request assistance in completing the review request. A review may be expedited if there is a stated immediate need for health services.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Michigan MI-20-0022

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

August 23, 2021

Kate Massey Medicaid Director State of Michigan, Department of Community Health 400 South Pine Street Lansing, MI 48913

Dear Ms. Massey:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) MI- 20-0022 submitted on September 30, 2020, with additional information received on August 19, 2021, has been approved. Through this SPA, Michigan added coverage of mental health (MH) and substance use disorder (SUD) benefits for its CHIP unborn population that are identical to the MH/SUD benefits provided to pregnant women under the Medicaid state plan. By adding these benefits, the state demonstrates compliance with section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, as further described below. The SPA effective date is October 1, 2020, except for the implementation of the state’s strategies to facilitate the use of validated behavioral health screening tools, which has an effective date of January 1, 2021.

Section 5022 of the SUPPORT Act added section 2103(c)(5) to the Social Security Act (the Act) and requires child health and pregnancy related assistance to include coverage of services necessary to prevent, diagnose, and treat a broad range of behavioral health symptoms and disorders. Additionally, section 2103(c)(5)(B) of the Act requires that behavioral health services be delivered in a culturally and linguistically appropriate manner. Michigan demonstrated compliance by providing the necessary assurances and benefit descriptions that the state covers a range of behavioral health services in a culturally and linguistically appropriate manner.

Your Project Officer is Ms. Dietrich Graham. She is available to answer your questions concerning this amendment and other CHIP-related matters. Ms. Graham’s contact information is as follows:

Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations 233 North Michigan Avenue, Suite 600 Chicago, IL 60601 Telephone: (312) 353-9355 E-mail: Dietrich.Graham@cms.hhs.gov

Page 2- Ms. Kate Massey

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

Smncerely,

/Signed by Amy Lutzky/

Deputy Director

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

Effective Date: October 1, 2020

Approval Date: 1

OMB #: 0938-0707 Exp. Date:

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

Preamble

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

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

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

Form CMS-R-211

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

Effective Date: October 1, 2020

Approval Date: 2 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDRENS HEALTH INSURANCE PROGRAM

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

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

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

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

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

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Logan Dreasky

Position/Title: Manager, Eligibility Policy Section Name:

Position/Title: Name:

Position/Title:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.

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

Effective Date: October 1, 2020

Approval Date: 3 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

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

1.1.1

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

1.1.2.

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

1.1.3. X A combination of both of the above.

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

Michigan received federal approval to implement MIChild effective May 1, 1998. All claimed expenditures were after May 1, 1998.

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

Michigan complies with the above by including the following statements on the application:

Michigan Department of Health and Human Services (MDHHS) will not discriminate against any individual or group because of race, sex, religion, age, national origins, marital status, disability or political beliefs.”

“If you need help with this application, call toll free 1-888/988-6300

Spanish: If you need help with this application, call toll free 1-888/988-6300

Arabic: If you need help with this application call toll free 1-888/988-6300”

“If you need help with reading or writing to complete this application, under the Americans with Disabilities Act, you are invited to make your needs known by calling 1-888/988-6300 or your local FIA office.”

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

Effective Date: October 1, 2020

Approval Date: 4

“You have the right to appeal a decision made by the MDHHS. You will be notified of your rights if your application is denied for any reason.”

1.4

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

Date of Plan Submitted: December 29, 1997 Date Plan Approved: April 7, 1998 State Plan Effective Date: May 1, 1998

Date Amendment #1 Submitted: April 16, 1998 Date Amendment #1 Effective: May 1, 1998

Date Amendment #2 Submitted: December 21, 1998 Date Amendment #2 Effective: January 1, 1999

Date Amendment #3 Submitted: May 28, 1999 Date Amendment #3 Effective: June 28, 1999

Date Amendment #4 Submitted: May 30, 2000 Date Amendment #4 Effective: July 1, 2000

Date Amendment #5 Submitted: August 13, 2001 Date Amendment #5 Effective: July 1, 2001

Date Amendment #6 Submitted: December 20, 2003 Date Amendment #6 Effective: July 1, 2002

Date Amendment #7 Submitted: January 9, 2003 Date Amendment #7 Effective: December 1, 2002

Date Amendment #8 Submitted: June 1, 2005 Date Amendment #8 Effective: November 1, 2005

Date Amendment #9 Submitted: January 16, 2007 Date Amendment #9 Effective: October 1, 2006

Date Amendment #10 Submitted: March 8, 2007 Date Amendment #10 Effective: April 1, 2007

Date Amendment #11 Submitted:

March 30, 2010 Date Amendment #11 Effective

January 1, 2010

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

Effective Date: October 1, 2020

Approval Date: 5 Date Amendment #12 Submitted:

August 28, 2010 Date Amendment #12 Effective:

October 1, 2010

Date Amendment #13 Submitted:

September 28, 2011 Date Amendment #13 Effective:

October 1, 2010

Date Amendment #14 Submitted:

February 21, 2013 Date Amendment #14 Effective:

April 1, 2013

Date Amendment #15 Submitted:

October 4, 2013 Date Amendment #15 Withdrawn:

October 14, 2013

Date Amendment #16 Submitted:

March 21, 2014 Date Amendment #16 Effective:

July 1, 2014

Date Amendment #MI-15-0001-CHIP Submitted: March 31, 2015 Date Amendment #MI-15-0001-CHIP Withdrawn: June 4, 2015

Date Amendment #MI-15-0002-CHIP Submitted: December 17, 2015 Date Amendment #MI-15-0002-CHIP Effective: January 1, 2016

Date Amendment #MI-16-0017-CHIP Submitted: November 3, 2016 Date Amendment #MI-16-0017-CHIP Effective: January 1, 2017

Date Amendment #MI-17-0018-CHIP Submitted: September 7, 2017 Date Amendment #MI-17-0018-CHIP Effective: January 1, 2017

Date Amendment #MI-18-0019-CHIP Submitted: August 8, 2018 Date Amendment #MI-18-0019-CHIP Effective: October 2, 2017

Date Amendment #MI-19-0020-CHIP Submitted: May 23, 2019 Date Amendment #MI-19-0020-CHIP Effective for lead abatement HSI:

January 1, 2019 Date Amendment #MI-19-0020-CHIP Effective for Poison Control HSI:

August 1, 2019

Date Amendment #MI-20-0021-CHIP Submitted: September 30, 2020 Date Amendment #MI-20-0021-CHIP Effective: March 1, 2020 Disaster Relief SPA Not Yet Approved

Date Amendment #MI-20-0022-CHIP Submitted: September 30, 2020 Date Amendment #MI-20-0022-CHIP Effective: October 1, 2020

Superseding Eligibility Pages of Modified Adjusted Gross Income (MAGI) CHIP State

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

Effective Date: October 1, 2020

Approval Date: 6 Plan Material State: Michigan

Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) MI-13-0001

Date Submitted: 12/20/13 Approval Date: 10/09/14 Effective/Implemen tation Date: January 1, 2014 MAGI Eligibility & Methods CS7

CS9

CS15 Eligibility – Targeted Low Income Children

Eligibility – Coverage from Conception to Birth

MAGI-Based Income Methodologies

Supersedes the current sections 4.1.1, 4.1.2 and 4.1.3

Supersedes the current sections 4.1.1, 4.1.2 and 4.1.3

Incorporated within a separate subsection under section 4.3

MI-13-0002

Date Submitted: 12/20/13 Approval Date: 12/22/14 Effective/Implemen tation Date: January 1, 2014

XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current Medicaid expansion section 4.0 MI-13-0003

Date Submitted: 12/20/13 Approval Date: 03/17/14 Effective/Implemen tation Date: January 1, 2014

Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporated within a separate subsection under section 4.1 MI-13-0004

Date Submitted: 12/20/13 Approval Date: 03/11/14 Eligibility Processing CS24 MAGI-Based Eligibility Process Supersedes the current items in sections 4.3 and 4.4 related to application processing, eligibility screening

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

Effective Date: October 1, 2020

Approval Date: 7 Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) Effective/Implemen tation Date: October 1, 2013

and enrollment, and renewals

MI-13-0005

Date Submitted: 12/20/13 Approval Date: 12/17/15 Effective/Implemen tation Date: January 1, 2014

Effective/Implemen tation Date for CS20 only: January 24, 2014

Non-Financial Eligibility

CS17

CS18

CS19

CS20

CS21

Non-Financial Eligibility – Residency

Non-Financial Eligibility – Citizenship

Non-Financial Eligibility – Social Security Number

Non-Financial Eligibility – Substitution of Coverage

Non-Financial Eligibility – Non-Payment of Premiums

Supersedes the current section 4.1.5

Supersedes the current section 4.1.0

Supersedes the current section 4.1.9

Supersedes the current section 4.4.4

Supersedes the current Cost Sharing and Payment section 8.7

MI-15-0003

Date Submitted: 12/17/15 Approval Date: 03/08/16 Effective/Implemen tation Date: January 1, 2016

XXI Medicaid Expansion

CS3

Eligibility for Medicaid Expansion Program

Supersedes the current Medicaid expansion section 4.0 and MI-13-0002

MI-15-0004

Date Submitted:

Non-Financial Eligibility

CS21

Non-Financial Eligibility – Non-Payment of

Supersedes the current Cost Sharing and Payment section

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

Effective Date: October 1, 2020

Approval Date: 8 Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) 12/17/15 Approval Date: 03/08/16 Effective/Implemen tation Date: January 1, 2016 Premiums 8.7

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

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

State Response: Much attention has been given to the problem of the lack of health insurance coverage for the unborn child in low-income families whose incomes are at or below 195 percent of the Federal Poverty Level and who are uninsured. This is the baseline figure used by Michigan as the target for Medicaid or Maternity Outpatient Medical Services (MOMS) enrollment.

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

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

State Response: Michigan currently has several programs focused on identifying potentially eligible Medicaid clients and assisting them to complete enrollment forms to become Medicaid recipients. All local health departments in the state have at least two sources of funding specifically for outreach to families and children not currently enrolled in Medicaid and for provision of assistance in applying for Medicaid eligibility.

Medicaid provides funding to all forty-two local health departments so they can identify pregnant women whose unborn child is not currently enrolled in Medicaid, assist them in completing enrollment materials, and in selecting and obtaining access to health care providers serving Medicaid eligible pregnant women and the unborn child. The health departments also

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

Effective Date: October 1, 2020

Approval Date: 9 have a Prenatal Care Enrollment and Coordination Program which provides outreach to facilitate access to prenatal care through the Healthy Kids Program, and assistance in obtaining access to a prenatal care provider. This program also provides families with assistance in completing Medicaid enrollment forms for children, which are then forwarded to Medicaid for determination of eligibility. Services provided through this program include assistance in completion of the, Medicaid application gathering all required verifications, negotiating the Medicaid system, obtaining health care providers, responding to managed care problems/concerns, and obtaining access to other support programs.

Several other programs provide outreach for special populations as identified below.

• Maternal Support Services (MSS): Pregnant women and teens that are potentially Medicaid-eligible are assisted in obtaining Medicaid enrollment by providers throughout the state. As with the ISS program, both public and private agencies are providers. This program also provides services to non-Medicaid-eligible women and teens with additional state funding made available for this purpose.

•

Maternal and Infant Health Advocacy Services Program (MIHAS): This program provides outreach to pregnant women who are not currently receiving prenatal care, assists them in dealing with situations which may keep them from remaining in prenatal care, and supports and reinforces the health education messages delivered by health care providers. MIHAS services are delivered by a team of paraprofessional advocates and a supervisor specifically trained to deal with the psychosocial problems of high-risk, low-income pregnant women. Paraprofessional advocates must be indigenous to the community and have been on Medicaid.

•

Special Supplemental Nutrition Program for Women, Infants and Children (WIC): WIC screens and refers clients to other appropriate health and social services, including Medicaid, food stamps, prenatal care, immunizations, smoking cessation programs, and substance abuse programs. Referral of WIC clients for Medicaid enrollment is a required outreach activity in this program. Nearly half of the infants born in Michigan are served by the WIC Program, making this an important source of outreach for Medicaid enrollment.

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

State Response: Prenatal Care Enrollment and Coordination Program provides outreach to facilitate access to prenatal care and assistance in obtaining access to a prenatal care provider. Michigan is working with Covering Kids, a national public/private partnership, by providing staffing and materials to promote education and outreach at health-related conferences. The

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

Effective Date: October 1, 2020

Approval Date: 10 Michigan initiative is called Covering Michigan’s Kids.

NOTE: In the revised “Template for Child Health Plan under title XXI of the Social Security Act Children’s Health Insurance Program,” section 2.2 is designed specifically for states to request to use the funds available under the 10 percent limit on administrative expenditures to implement a health services initiative. The revised section 2.2 reads as follows:

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

As permitted under section 2105(a)(1)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, the State of Michigan is doing a health services initiative that will use CHIP funds, within the federal administrative expenditures cap allowed for states, to support the Michigan Poison Control Center (MPCC) at Wayne State University. Effective August 1, 2019, the MPCC administration will transition from Children’s Hospital of Michigan to Wayne State University. Separate payments will be made to each entity based on the periods of administration. The MPCC provides emergency telephone treatment advice, referral assistance, and information to manage exposures to poisonous and hazardous substances. The MPCC answers poisoning emergency calls from the general public as well as health care providers needing assistance 24 hours a day, 365 days each year at no charge to the caller.

The MPCC provides numerous services including:

• 24-hour emergency and information hotline services • follow-up calls regarding continuing care in poison exposure cases • health and safety professional education • state and national data collection providing epidemiologic public health surveillance • access to emergency information as an integral part of local, state and national emergency preparedness • responses for natural and manmade disasters • acting as a clearinghouse for scarce resources and antidotes • providing guidance in the treatment of hazardous incidents to the public • providing interpretative assistance of forensic data for law enforcement and medical examiners • assisting other federal and state agencies in risk-assessment for potentially toxic exposures

Certified Specialists in Poison Information and medical or clinical toxicologists are available 24 hours a day, 365 days a year to manage cases. The service is provided via a toll-free

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

Effective Date: October 1, 2020

Approval Date: 11 telephone number to every community throughout Michigan, including under-served, low income, and indigent populations. Services are available by use of an interpreter in over 150 languages and via telecommunications devices for the deaf and hearing impaired (TTY).

The MPCC provides public education programs directed towards pediatric accidental poisoning as well as targeted “at-risk” populations. Educational materials and teaching curricula are distributed throughout the state, free of charge to the public. Materials are also available in Spanish and Arabic. The MPCC participates in a variety of community injury prevention including health fairs. The MPCC also provides a robust professional educational program designed to train medical and safety professionals in the identification and treatment of poisoning and hazardous exposures including pre-hospital and first-responder training.

The MPCC receives approximately 64,000 calls annually involving individuals exposed to poisons or hazardous substances. Sixty percent of all poisoning exposure calls received involve children under age 19. For CHIP eligible children, over 33 percent of the total calls relate to poisoning exposures of children in families whose annual household incomes is $51,500 or less (200% FPL for a family of 4 in 2019). In addition to calls regarding exposures, the MPCC receives over 10,000 calls each year from callers requesting information about poison prevention, effective use of chemicals, drug identification, substance abuse and other medical questions. These calls are considered preventive.

MPCC intervention resulted in over 71 percent of the unintentional exposure calls (in children under age 19) being handled in the home so the children did not have to use an emergency department or need a 911 call and response. For those children whose exposure necessitated hospital evaluation and treatment, MPCC intervention contributed substantially to reduced resource utilization and decreased length of stay with significant cost savings to the community.

The state assures that the Michigan Poison Control Center (MPCC) at Wayne State University will not supplant or match CHIP federal funds with other federal funds, nor allow other federal funds to supplant or match CHIP federal funds.

As permitted under section 2105(a)(1)(D)(ii) of the Social Security Act and federal regulations at 42 CFR 457.10, the State of Michigan is doing a health services initiative that will use CHIP funds, within the federal administrative expenditures cap allowed for states, to support expanded lead abatement activities in the impacted areas of Flint, Michigan and other areas within the State of Michigan, as further described herein. Federal assistance is necessary to minimize and further prevent any long-term adverse health effects associated with lead exposure, both in Flint and across Michigan. This targeted and time-limited health services initiative would complement other federal, state and local efforts to abate lead hazards from the homes and improve the health of Medicaid and CHIP eligible individuals.

Lead Abatement Defined

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

Effective Date: October 1, 2020

Approval Date: 12

As alluded to in Michigan’s February 14, 2016 application for the now approved Section 1115 Demonstration, the State is seeking federal funding pursuant to Section 2105(a)(1)(D)(ii) of the Social Security Act for the enhancement and expansion of its current lead abatement program through the use of a CHIP health services initiative. As part of this expansion, the State would provide coordinated and targeted lead abatement services to eligible properties in the impacted area to mitigate all lead risks to the extent possible up to the point of family and/or property owner disengagement. Abatement services are defined as the removal of lead hazards, including: • The permanent removal, or enclosure, or encapsulation of lead based paint and lead dust hazards from an eligible residence. • The removal and replacement of surfaces or fixtures within the eligible residence. • The removal or covering of soil lead hazards up to the eligible residence property line. • Minimal rehab to the extent that this work helps to extend the life of the lead abatement work done consistent with HUD guidelines (located at https://www.hud.gov/offices/lead/library/lead/PGI-2008-02_Doing_Minimal_Rehab.pdf) and any subsequent amendments to the HUD guidelines, and • All preparation, lab sampling analysis, clean up, disposal, and pre and post-abatement paint, dust, soil and clearance testing activities associated with such measures including pre and post-water sampling.

Eligible properties include owner-occupied, rental, and residential structures that an eligible individual inhabits or visits regularly (e.g. home of a family member, relative, or other informal child care where a child often visits). A rental property funding scale for those with ownership stake in more than 1 rental property may be established to reduce the CHIP HSI federal and state program spending on the related projects and maximize the number of homes in which the program provides abatement assistance and to ensure that the program is able to enroll high cost projects in the program equitably among property owners. Project cost must be approved by Regional Field Consultant to align with estimate and Healthy Homes Section Manager. There is currently no maximum funding cap placed on rental unit projects however, rental property owners may be asked to provide match to the project as follows: Number of Units Owned by RPO, in addition to enrolled unit (s) Maximum Assistance Provided PER UNIT, by LSHP- Based on number of units enrolled

Single Family Unit 2-4 Units Adjoined >5 units Adjoined 1 100%

2-4 95% 85% 75% >5 80% 70% 60%

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

Effective Date: October 1, 2020

Approval Date: 13 Once work has started on an eligible property, all eligible surfaces and fixtures will be abated to the extent possible up to the point of family and/or property owner disengagement. A client engagement protocol is being implemented by the state to maximize participation. Eligible surfaces for abatement activities include all structural components identified during an environmental investigation or the lead inspection/risk assessment as hazards including but not limited to: all window components, door and door frames, stairs, interior walls and ceilings, painted cabinets, interior railings, painted floors, exterior porches, exterior painted siding, exterior windows and trim, exterior trim boards, exterior painted siding, trim and doors on garages and other structures, and soil. Eligible fixtures includes all interior plumbing components with the general exception of the interior water meter, which will be addressed in accordance with each community’s coordinated plan. In Flint, this also includes the exterior lead and galvanized steel service lines that supply drinking water to the home, which shall be completed concurrently or prior to abatement of interior plumbing fixtures funded through this initiative. Outside of Flint, the State will recommend replacement of faucets that have not been replaced prior to 2014 regardless of water sample result, and fixture and/or complete lead and galvanized steel service line replacement if water sampling results are above the acceptable level. A home shall not be deemed abated if water results indicate the presence of lead in the water supply line over the acceptable level.

The state assures that no partial service line replacements will be conducted under this health services initiative. Service line replacement must be “complete,” meaning that both the public and private portions of the service line will be replaced. The state will supplement, not supplant, other federal, state, and local funds allocated for the removal of service lines. For the purposes of this request, abatement does not include any of the following:

• Work that does not reduce a lead hazard.

• Work not performed by a certified lead abatement professional and/or a licensed plumber

• Work that is not the responsibility of the property owner or landlord outside the confines of the property lines, with the exception of the public portion of service lines in Flint and on a case by case basis in other communities following the guidelines put forth in this health services initiative.

• Work on dwellings that have not been determined at application to have an eligible Medicaid or CHIP individual, under the age of 19, or pregnant women residing or frequently visiting the structure.

Provision of Abatement Services

For this health services initiative, abatement activities would only be permissible for federal funds if the services are delivered to properties that have been determined at application to have a Medicaid or CHIP-eligible individual, under the age of 19, or pregnant woman residing or visiting regularly. Services may be rendered to the physical structure and include the surrounding land up to the

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

Effective Date: October 1, 2020

Approval Date: 14 property line, and would be coordinated with any service line removal that occurs outside of the property line. Federal funds can be used to support family relocation costs for up to 10 days if needed consistent with HUD guidelines and any subsequent amendments to the HUD guidelines. This limit on relocation day support can be extended on a case by case basis. This SPA will be in effect for five years from the effective date or until all homes included in the scope of this SPA have been abated for lead.

The State will ensure that eligible properties in the impacted areas of Flint, Michigan receive priority status. Upon approval of this health services initiative, outreach will begin to identify eligible properties and engage affected beneficiaries in Flint. The State will concurrently begin identifying other high-risk communities within Michigan that will be targeted for health services initiative- approved abatement activities. Target communities will be selected based on the following criteria: • Number/percentage of population under age 6 with an elevated blood lead level of ≥ 5 ug/dL; • Percentage of population that is low-income; • Number/percentage of pre-1978 and pre-1940 housing stock; and • Other social determinant factors (e.g. unemployment rate, number/percentage of children receiving state assistance and housing conditions).

Medicaid or CHIP-eligible beneficiaries that have a blood lead level ≥ 5 ug/dL in non-target areas will also be eligible for abatement activities.

In Flint, abatement services on eligible properties must be coordinated with the ongoing state and local water service line efforts. Interior plumbing and fixture abatement will be done only after service line replacement, if required under this health service initiative, has been completed. In Flint, interior plumbing and fixture abatement may occur prior to service line replacement if the city of Flint is handling the replacement of the service line. In such circumstances, after the replacement of the service line is complete, a whole house flushing procedure that will include allowing the water to flush through the plumbing, removing and cleaning aerators or replacing them if necessary, and testing of water samples to ensure no recontamination of the interior plumbing and fixtures must be performed.

Prior to starting work on homes in additional target areas, the State will notify CMS 60 days prior to work beginning in those communities. Additionally, the State will work with each community to develop a coordinated plan to guide these lead abatement activities. Services performed must be part of a comprehensive plan that ensures abatement activities of the eligible individual’s residence align with the affected infrastructure needs (if applicable).

Individuals performing abatement services must be properly certified by the state. Only a person certified by MDHHS as a lead abatement supervisor or lead abatement worker may perform lead abatement activities in accordance with state law. A supervisor is defined as an individual who has been trained by an accredited training program and certified by MDHHS to supervise and conduct lead abatement services and to prepare occupant protection plans and abatement reports. A lead abatement supervisor is required for each lead abatement job, and must be present at the job site while all abatement work is being done. This requirement includes set up and clean up time. The lead

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

Effective Date: October 1, 2020

Approval Date: 15 abatement supervisor must ensure that all abatement work is done within the limits of federal, state, and local laws.

A lead abatement worker is an individual who has been trained to perform abatements by an accredited training program and who is certified by MDHHS to perform lead abatement. Professionals certified by MDHHS are issued a card containing the person’s picture, name, certification number, and expiration date. All certified professionals must work for a MDHHS certified lead abatement company. The abatement company and its employees must use abatement methods approved by the U.S. Department of Housing and Urban Development (HUD) and/or the U.S. Environmental Protection Agency (EPA) and in accordance with state laws and regulations.

The department may certify entities who meet the professional requirements for lead and galvanized steel service line removal and have been contracted to do such work under an approved coordinated plan.

For the purposes of this health services initiative, MDHHS requests funding to supplement the training of individuals in lead abatement in accordance with Michigan Compiled Law 333.5461 – 333.5468. Individual training for certification/licensure must occur through an accredited training program specific to lead. These funds will ensure that access to appropriate levels of lead professionals are available to mitigate lead risks in a timely manner.

Lastly, MDHHS requests funding to supplement the administrative functions necessary to successfully implement this CHIP health services initiative. The funding received for this request will supplement but not supplant other federal funding sources for lead abatement or the training/credentialing process of inspectors.

Post-Abatement Activities

MDHHS recognizes that abatement activities would only be eligible for federal assistance when performance of these activities can be demonstrated to be effective in abating all identified lead hazards and extending the life of the related abatement activities. State and federal laws dictate that a clearance test must be performed after any lead abatement work is finished to verify the work area is safe enough for the eligible resident(s) to return. On the inside of a house or apartment the dust is tested to confirm that abatement work has not created lead dust hazards that can poison young children, other occupants, or pets living in the building as defined in state law. Water sampling will also be conducted to confirm that respective plumbing component replacement has successfully reduced lead levels in the drinking water of affected homes.

Only a certified lead inspector or risk assessor, who is independent of the abatement company, may perform clearance testing after abatement work is completed. A certified inspector is defined as an individual who has been trained by an accredited training program and certified by MDHHS to conduct inspections and take samples for the presence of lead in paint, dust and soil for the purpose of abatement clearance testing. A certified risk assessor is defined as an individual who has been trained by an accredited training program and certified by MDHHS to conduct inspections and risk

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

Effective Date: October 1, 2020

Approval Date: 16 assessments and to take samples for the presence of lead in paint, dust and soil for the purpose of abatement clearance testing.

During the clearance testing, an interior visual inspection is done to see if the identified lead hazards have been abated. These professionals also inspect for the presence of any visible dust or paint chips. If any problems are found the abatement supervisor must resolve all of them before the clearance testing may continue. After the visual inspection passes, the lead inspector or risk assessor must take dust wipe samples that are sent to a lab for analysis. Clearance dust samples must be taken from the floors, windowsills, and window troughs in the rooms where work was done. At least one sample must be taken from outside the work area if containment was used and from each unique passage way. If no containment was used, then dust wipe samples may be taken in any room. A floor and a window in at least four rooms must be sampled. The samples must be tested for lead by an EPA approved lab. After exterior paint abatement work is completed, an Inspector or Risk Assessor must perform a visual inspection of the outdoor work area ensure that the lead hazards were properly addressed. The lead inspector or lead risk assessor will then look for any paint chips on the ground including the foundation of the house, garage, or below any exterior surface abated. If paint chips are present, the abatement company must remove the chips and debris from the site and properly dispose of them before the clearance can be finished. No dust wipe clearance testing is required for abatement on the exterior of a house or rental property.

Water sampling protocols will follow prescribed methodology required in the EPA Lead and Copper rule.

Metrics/Reporting Requirements

The state believes that this health services initiative will abate identified lead hazards from the homes and improve the health of Medicaid and CHIP eligible individuals, both in Flint and throughout Michigan. Providing for enhancement and expansion of the lead hazard removal program will reduce the potential for ongoing exposure or re-exposure to lead hazards for the eligible population and future populations. A publicly-available housing registry of these ameliorated properties will be maintained by the state.

Key Metrics the state will track and report to CMS monthly or at another approved interval include:

• Number of houses identified with high levels of lead hazards in each of the targeted area(s)

• The number of homes in each of the targeted areas scheduled for lead hazard abatement.

• The number of homes in each of the targeted areas in which lead hazard abatement has occurred.

 Number of houses abated for pregnant women.

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

Effective Date: October 1, 2020

Approval Date: 17  Number of houses abated for CHIP or Medicaid children under the age of 19.

• Record of actual services provided in each house.

• Clearance testing results.

• Percentage of children receiving blood lead testing under EPSDT statewide and in the areas targeted by this health services initiative.

• Percentage of children with elevated blood lead levels statewide and in the areas by this health services initiative.

Other metrics may be added at the agreement of the state and CMS during implementation of the HSI.

The results of the clearance testing will be maintained by the state. These testing results will have numbers with units of measurement; the units are different for dust and soil. EPA and HUD regulations define clearance lead levels with the values and units of measurement shown in the table below.

Material Tested Considered hazardous if lead is present at or above these levels* Bare soil (child play areas) At or above 400 parts per million (ppm) of lead in the soil Bare soil (other areas) At or above 1200 ppm of lead Water

Equal to or more than 15 parts per billion (ppb) of lead in water House dust (floors)

At or above 40 micrograms of lead per square foot of sampled area (ug/ft2) House dust (window sills) At or above 250 ug/ft2 of lead House dust (window troughs)

At or above 400 ug/ft2 of lead Paint tested by an X-Ray Fluorescence (XRF) analyzer

equal to or more than 1.0 milligrams per square centimeter (mg/cm2) of lead on a deteriorated sampled surface or an elevated dust wipe sample corresponding to the lead surface Paint tested by paint chip analysis

equal to or more than 0.5% (one half of 1 percent) lead by dry weight, or equal to or more than 5,000 parts per million of lead in paint (ppm) * All levels indicated in the table above will be utilized until and unless more stringent guidelines are promulgated at the state or federal level.

The state assures that this health services initiative will not supplant or match CHIP federal funds with other federal funds, nor allow other federal funds to supplant or match CHIP federal

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

Effective Date: October 1, 2020

Approval Date: 18 funds.

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

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

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

Guidance: In Section 3.1, describe all delivery methods the State will use to provide services to enrollees, including: (1) contracts with managed care organizations (MCO), prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), primary care case management entities (PCCM entities), and primary care case managers (PCCM); (2) contracts with indemnity health insurance plans; (3) fee-for-service (FFS) paid by the State to health care providers; and (4) any other arrangements for health care delivery. The State should describe any variations based upon geography and by population (including the conception to birth population). States must submit the managed care contract(s) to CMS’ Regional Office for review.

3.1.

Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care

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

Effective Date: October 1, 2020

Approval Date: 19 delivery system and some of the CHIP population is included in a fee-for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2.

Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s

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

Effective Date: October 1, 2020

Approval Date: 20 responses to the following questions will only apply to those populations.

State Response: Medical services for the unborn child will be provided on a fee-for- service basis. All pregnancy-related services must be determined to be medically necessary. Medical service coverage for unborn children is limited to the following prenatal and pregnancy- related services:

• Prenatal Care • Maternal Support Services (MSS) • Note: Pre-pregnancy family services and supplies are not covered for unborn children, • Labor and delivery: Professional services fee, including live birth, miscarriage, ectopic pregnancy, and stillborn. • Radiology and ultrasound • Childbirth education • Laboratory • Pharmaceuticals and prescription vitamins • Inpatient Hospital for Delivery Only • Outpatient Hospital • Note: Outpatient deliveries are not covered.

MDHHS , which includes public health, mental health and Medicaid, is committed to the development and implementation of community-based collaborative efforts to assist the pregnant woman and her unborn child Multipurpose Collaborative Bodies have been established throughout the state and are charged with community-based planning and service provision. These collaborative bodies include public and private agencies and organizations focused on prenatal care for all unborn children.

The program developed under Title XXI will utilize the current networks described above to publicize the availability of prenatal coordinate activities that include assisting pregnant women and the unborn child and utilize various transportation, interpreter and other support services to enhance access to health care providers.

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

State Response: The State anticipates a capitation methodology of payment. The State will use its actuarial contractor to establish appropriate rates.

With a risk-based model, the state’s oversight focus will be concentrated on ensuring

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

Effective Date: October 1, 2020

Approval Date: 21 that needed, quality services are received rather than focusing on issues attendant to service over-use. If the medical services reimbursement mechanism is non risk-based, the State will be equally sensitive to possibilities of service over-use and concerns of accessibility and quality of services received.

Utilization controls/reviews are detailed extensively after Section 7.1 after the heading “State Oversight and Monitoring.”

Federally Qualified Health Center (FQHC) and Rural Health Center (RHC)

Section 503 of CHIPRA amends section 2107(e) (l) of the Act to make section 1902(bb) of the Act applicable to CHIP in the same manner as it applies to Medicaid. Section 1902(bb) governs payment for Federally Qualified Health Centers (FQHC's) and Rural Health Clinics (RHC's).

FQHC's and RHC's will be reimbursed based on the Medicaid Prospective Payment System (PPS). PPS was enacted into law under section 702 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000. Under the PPS, FQHC's and RHC's will be reimbursed on a per visit basis. The per visit payment is the Medicaid State plan PPS rate, effective for services provided on or after October 1, 2009. Reasonable costs are defined as the per visit amount approved by Medicare as adjusted to reflect the cost of providing services to CHIP beneficiaries that are not covered by Medicare – i.e. dental services, on-site laboratory and x-ray, non-emergency transportation, and outreach.

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

Effective Date: October 1, 2020

Approval Date: 22 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

*Policy narrative is superseded by forms listed in roster 1.4

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

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

4.1.1. X Geographic area served by the Plan: Statewide

4.1.2 Age: conception through birth

4.1.3. X Income: at or below 195% percent of the federal poverty level For children from conception through birth, the adjusted gross income is 0 to 195% of the federal poverty level (FPL).

4.1.4 X Resources (including any standards relating to spend downs and disposition of resources): No resource test

4.1.5. X Residency (so long as residency requirement is not based on length of time in state) : Must be a resident of Michigan or be in Michigan to seek employment.

4.1.6. ∼ Disability Status (so long as any standard relating to disability status does not restrict eligibility): None

4.1.7. X Access to or coverage under other health coverage State Response: Comprehensive employer-based coverage by other creditable health insurance will preclude enrollment in this program

4.1.8. X Duration of eligibility:

State Response: Eligibility continues from the date of application through two months post partum.

4.1.9 Other standards (identify and describe): Applicants are required to provide a Social Security Number or they must have applied for SSN. Not required of others.

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

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

Effective Date: October 1, 2020

Approval Date: 23 4.2.1. X These standards do not discriminate on the basis of diagnosis. 4.2.2. X Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3. X These standards do not deny eligibility based on a child having a pre- existing medical condition.

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

State Response: The following process will be used to determine eligibility and continued enrollment:

. ENROLLMENT PROCESS

• receive completed applications and any required verifications,

• determine initial eligibility based on information presented,

.

BEGIN DATE OF ENROLLMENT

Eligibility begins on the first day of the month of application with retroactive coverage to the date of pregnancy up to 3 months prior to the applications date..

ELIGIBILITY CRITERIA

In order to be eligible for coverage for the unborn child • The unborn child must be a resident of Michigan, • Must reside in a family with an adjusted gross income of less than or equal to 195 percent of poverty No asset test is used. The income will be verified by self-declaration.

• The pregnant woman of the unborn child must have no comprehensive employer-based insurance coverage. Coverage through the CSHCS program and the Indian Health Services is not to be considered as other insurance for eligibility purposes.

QUALITY ASSURANCE/MONITORING

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b)) X Check here if this section does not apply to your state.

4.4. Describe the procedures that assure that:

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

Effective Date: October 1, 2020

Approval Date: 24 4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic re-determination, that only targeted low- income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including access to a state health benefits plan) are furnished child health assistance under the state child health plan. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)) (42 CFR 457.310(b) (42CFR 457.350(a)(1)) 457.80(c)(3))

State Response: The State will perform post-eligibility audits of the applications to assure compliance with eligibility and enrollment policies. In addition, part of the quality assurance methodology will be planned reports on the following:

• list of enrollees by county (this will be compared to the Medicaid population to assure the enrollee is not receiving both Medicaid and non-Medicaid CHIP (Maternity Outpatient Medical Services (MOMS) • number of applications received

• number of denials of applications with the reasons for denial

• corrective actions, regarding program compliance (e.g., presumptive eligibility)

Application reviews will include assurance that any required verifications have been used, time frames have been met, and appropriate referrals have been made.

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

State Response: Department staff will determine if the child is Medicaid

If the Department determines the unborn child to be Medicaid eligible, the unborn child will NOT be enrolled in the MOMS. If the Department determines the unborn child to be ineligible for Medicaid they will have eligibility determined for MOMS.

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

If the Department determines the unborn child to be Medicaid ineligible, the application will be reviewed at that time to determine eligibility in MOMS

4.4.4 The insurance provided under the state child health plan does not substitute for

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

Effective Date: October 1, 2020

Approval Date: 25 coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. x Coverage provided to children in families at or below 195 % FPL: describe the methods of monitoring substitution.

State Response: The application form will include a request for information regarding other insurance coverage. Pregnant women who have creditable employer based health coverage which provides prenatal services to the unborn child will not be enrolled in MOMS. 4.4.4.2.  Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

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

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

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

The minimum employer contribution.

The cost-effectiveness determination.

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

State Response: Outreach efforts will include the Indian Health Centers and other agencies providing services to Native Americans.

The application form also indicates the American Indian ethnicity in its demographic information requested. Submitting this information is voluntary. Targeted outreach may be initiated if necessary.

Section 5. Outreach (Section 2102(c))

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

Effective Date: October 1, 2020

Approval Date: 26 Describe the procedures used by the state to accomplish:

Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

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

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

6.1.1 Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2.

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

6.1.3.

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

6.1.4. X Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1. Coverage the same as Medicaid State plan 6.1.4.2.  Comprehensive coverage for children under a Medicaid Section 1115 demonstration project

6.1.4.3.  Coverage that either includes the full EPSDT benefit or

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

Effective Date: October 1, 2020

Approval Date: 27 that the state has extended to the entire Medicaid population 6.1.4.4.  Coverage that includes benchmark coverage plus additional coverage 6.1.4.5.  Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6.  Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. X Other (Describe) Coverage to unborn children Medical services for the unborn child will be provided on a fee-for- service basis. All pregnancy-related services must be determined to be medically necessary. Medical service coverage for unborn children is limited to the following prenatal and pregnancy- related services:

• Prenatal Care • Maternal Support Services (MSS) • Note: Pre-pregnancy family services and supplies are not covered for unborn children, • Labor and delivery: Professional services fee, including live birth, miscarriage, ectopic pregnancy, and stillborn. • Radiology and ultrasound • Childbirth education • Laboratory • Pharmaceuticals and prescription vitamins • Inpatient Hospital for Delivery Only • Outpatient Hospital • Note: Outpatient deliveries are not covered.

6.2.

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

6.2.1. Inpatient services (Section 2110(a)(1)) 6.2.2 . Outpatient services (Section 2110(a)(2)) 6.2.3. Physician services (Section 2110(a)(3)) 6.2.4. Surgical services (Section 2110(a)(4)) 6.2.5. Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6. Prescription drugs (Section 2110(a)(6))

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

Effective Date: October 1, 2020

Approval Date: 28 6.2.7. ∼ Over-the-counter medications (Section 2110(a)(7)) 6.2.8 Laboratory and radiological services (Section 2110(a)(8)) 6.2.9. X Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) 6.2.10 Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11. Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11) 6.2.12. Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13. Disposable medical supplies (Section 2110(a)(13)) 6.2.14. ∼ Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15. Nursing care services (See instructions) (Section 2110(a)(15))

6.2.16. Abortion only if necessary to save the life of the mother (Section 2110(a)(16) 6.2.17 Dental services (Section 2110(a)(17)) 6.2.18 Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19 Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20. Case management services (Section 2110(a)(20)) 6.2.21 Care coordination services (Section 2110(a)(21)) 6.2.22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23. Hospice care (Section 2110(a)(23)) 6.2.24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25. ∼ Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26. Medical transportation (Section 2110(a)(26)) 6.2.27. ∼ Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28. ∼ Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

6.2-BH Behavioral Health Coverage Section 2103(c)(5) requires that states provide coverage to prevent, diagnose, and treat a broad range of mental health and substance use disorders in a culturally and linguistically appropriate manner for all CHIP enrollees, including pregnant women and unborn children. In general, service limitations are based on medical necessity unless otherwise noted.

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

Effective Date: October 1, 2020

Approval Date: 29

Guidance: Please attach a copy of the state’s periodicity schedule. For pregnancy-related coverage, please describe the recommendations being followed for those services.

6.2.1- BH Periodicity Schedule The state has adopted the following periodicity schedule for behavioral health screenings and assessments. Please specify any differences between any covered CHIP populations:

State-developed schedule American Academy of Pediatrics/ Bright Futures Other Nationally recognized periodicity schedule (please specify: United States Public Preventive Services Task Force- recommended for preventive services, including pregnant individuals) Other (please describe: )

6.3- BH Covered Benefits Please check off the behavioral health services that are provided to the state’s CHIP populations, and provide a description of the amount, duration, and scope of each benefit. For each benefit, please also indicate whether the benefit is available for mental health and/or substance use disorders. If there are differences in benefits based on the population or type of condition being treated, please specify those differences.

If EPSDT is provided, as described at Section 6.2.22 and 6.2.22.1, the state should only check off the applicable benefits. It does not have to provide additional information regarding the amount, duration, and scope of each covered behavioral health benefit.

Guidance: Please include a description of the services provided in addition to the behavioral health screenings and assessments described in the assurance below at 6.3.1.1-BH.

Service limitation: the state assures that any limits on the amount, duration, and/or scope of services of the below services can be exceeded if medically necessary.

6.3.1- BH Behavioral health screenings and assessments. (Section 2103(c)(6)(A))

6.3.1.1- BH The state assures that all developmental and behavioral health recommendations outlined in the AAP Bright Futures periodicity schedule and United States Public Preventive Services Task Force (USPSTF) recommendations graded as A and B are covered as a part of the CHIP benefit package, as appropriate for the covered populations.

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools in primary care practice, providing education, training, and technical resources, and covering the costs of administering or purchasing the tools.

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

Effective Date: October 1, 2020

Approval Date: 30

6.3.1.2- BH The state assures that it will implement a strategy to facilitate the use of age-appropriate validated behavioral health screening tools in primary care settings. Please describe how the state will facilitate the use of validated screening tools.

Facilitation strategy: The state of Michigan has policies and procedures that are outlined in its Medicaid Provider Manual regarding the use of standardized, age-appropriate, and validated behavioral health screening tools in the primary care setting. The Medicaid program also communicates with enrolled providers through provider L-letters to educate, inform, and/or clarify issues related to MDHHS policies and procedures. The state also has a dedicated website for Medicaid enrolled providers that includes policy information and resources.

6.3.2- BH Outpatient services (Sections 2110(a)(11) and 2110(a)(19))

Guidance: Psychosocial treatment includes services such as psychotherapy, group therapy, family therapy and other types of counseling services.

6.3.2.1- BH Psychosocial treatment Provided for: Mental Health Substance Use Disorder

Psychotherapy services description: Treatment activity designed to reduce maladaptive behaviors, maximize behavioral self-control, or restore normalized psychological functioning, reality orientation, remotivation, and emotional adjustment, thus enabling improved functioning and more appropriate interpersonal and social relationships. Evidence-based practices such as integrated dual disorder treatment for co-occurring disorders (IDDT/COD) and dialectical behavior therapy (DBT) are included in this coverage. Family Therapy is therapy for a beneficiary and family member(s), or other person(s) significant to the beneficiary, for the purpose of improving the beneficiary/family function. SUD Outpatient treatment is a non- residential treatment service with clinicians educated/trained in providing professionally directed alcohol and other drug (AOD) treatment or a community-based location with appropriately educated/trained staff. Individual, family or group treatment services may be provided individually or in combination. SUD treatment must be individualized based on the needs of the beneficiary in order to support sustained recovery.

Limits: Service limitations are based on medical necessity.

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

Effective Date: October 1, 2020

Approval Date: 31 6.3.2.2- BH Tobacco cessation Provided for: Substance Use Disorder

Tobacco cessation services description: The state covers tobacco cessation prevention education and treatment. Counseling services for tobacco cessation are covered. All FDA approved medications for smoking cessation are covered.

Additional services: Michigan Department of Health and Human Services Public Health Administration has a Smoking Cessation section that includes a tobacco quit line, connection to free or low-cost services and support for all Michigan residents.

Limits: Service limitations are based on medical necessity.

Guidance: In order to provide a benefit package consistent with section 2103(c)(5) of the Act, MAT benefits are required for the treatment of opioid use disorders. However, if the state provides MAT for other SUD conditions, please include a description of those benefits below at section 6.3.2.3- BH.

6.3.2.3- BH Medication Assisted Treatment Provided for: Substance Use Disorder

6.3.2.3.1- BH Opioid Use Disorder

Service description: opioid-dependent beneficiaries may be provided chemotherapy using methadone, buprenorphine and naltrexone as an adjunct to a treatment service. Covered services for Methadone and pharmacological supports and laboratory services, as required by DPT/CSAT regulations and the Administrative Rules for Substance Use Disorder Service Programs in Michigan. Decisions to admit an individual for methadone maintenance must be based on medical necessity criteria, satisfy the level of care determination using the six dimensions of the ASAM Criteria, and have an initial diagnostic impression of opioid dependency for at least one year based on current DSM criteria.

Pharmacy related services for OUD: Michigan covers all FDA approved drugs for MAT. These drugs are included on the Preferred Drug List and there are no prior authorization requirements on these medications. Tablet and film medications have daily prescribing limits consistent with the FDA approved labeling.

Coverage of MAT also includes counseling and psychotherapy services.

Additional services: The Opioid Heath Home Program Pilot program is

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

Effective Date: October 1, 2020

Approval Date: 32 limited to eligible geographic area sites. The goals of the program are to ensure seamless transition of care and to connect eligible beneficiaries with needed clinical and social services. This benefit enhances patient outcomes and quality of care, while simultaneously shifting people from emergency departments and hospitals to a primary care setting. Program services include: comprehensive physical and behavioral health care, comprehensive case management, care coordination and health promotion, comprehensive transitional care, patient and family support (including authorized representatives), referral to community and social support services, and use of health information technology to link services.

Limits: Service duration limits depend on ASAM Level and medical necessity.

6.3.2.3.2- BH Alcohol Use Disorder

Service description: Psychosocial treatment services are made available through county Community Mental Health Services and AUD programs including MAT services when needed.

Pharmacy services: all FDA approved medications for AUD are covered.

Limits: Service duration limits depend on ASAM Level and medical necessity.

6.3.2.3.3- BH Other

6.3.2.4- BH Peer Support Provided for: Mental Health Substance Use Disorder

Peer support services description: Peers are self-identified consumers in recovery from, serious mental illness, serious emotional disturbance, substance use disorders, and/or lived experience with intellectual and developmental disabilities; or a parent/adult with personal experience on-going or in the past of a child or family member with similar mental illness, intellectual and developmental disabilities, and/or substance use; and have experience and perspectives with navigating human service systems and supports. Peer-delivered or peer-operated support services are programs and services that provide individuals with opportunities to learn and share coping

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

Effective Date: October 1, 2020

Approval Date: 33 skills and strategies, move into more active assistance and away from passive roles, and to build and/or enhance self-esteem and self-confidence. Included programs: Drop-in centers, peer specialists, peer recovery coach, youth-peer support, peer support navigator, parent support partners, and peer with I/DD mentoring. SUD Peer Recover and Recovery Support and promote recovery and prevent relapse through supportive services that result in the knowledge and skills necessary for an individual’s recovery. Peer recovery programs are designed and delivered primarily by individuals in recovery (Recovery Coach) and offer social, emotional, and/or educational supportive services to help prevent relapse and promote recovery.

Limits: Service limitations are based on medical necessity.

6.3.2.5- BH Caregiver Support Provided for: Mental Health Substance Use Disorder

Caregiver support services description: Family-focused services provided to family of persons with serious mental illness, serious emotional disturbance, or developmental disability for the purpose of assisting the family in relating to and caring for a relative with one of these disabilities. Services target the family members who are caring for and/or living with an individual receiving mental health services. These services include education and training, counseling and peer support, Family Psycho-Education and Parent-to-Parent Support.

Limits: Service limitations are based on medical necessity.

6.3.2.6- BH Respite Care Provided for: Mental Health Substance Use Disorder

Respite care services description: respite care services are intended to assist in maintaining a goal of living in a natural community home. Respite care services are provided on a short-term, intermittent basis to relieve the beneficiary’s family or other primary caregiver(s) from daily stress and care demands during times when they are providing unpaid care.

Limits: Service limitations are based on medical necessity.

6.3.2.7- BH Intensive in-home services Provided for: Mental Health Substance Use Disorder

Intensive in-home services description: Mental health home-based services programs are designed to provide intensive services to beneficiaries and their families with multiple service needs who require access to an array of mental health services. The primary goals of these programs are to support families in meeting developmental

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

Effective Date: October 1, 2020

Approval Date: 34 needs, to support and preserve families, to reunite families who have been separated, and to provide effective treatment and community supports to address risks that may increase the likelihood of a child being placed outside the home. Treatment is based on beneficiary needs, with the focus on the family unit. The service style must support a family-driven and beneficiary-guided approach, emphasizing strength-based, culturally relevant interventions, parent/youth and professional teamwork, and connection with community resources and supports. Services are available for mental health diagnosis with co-occuring SUD.

Limits: Service limitations are based on medical necessity.

6.3.2.8- BH Intensive outpatient Provided for: Mental Health Substance Use Disorder

Intensive outpatient services description: For mental health conditions, with or without co-occuring SUD, Assertive Community Treatment (ACT) is a therapeutic set of intensive clinical, medical and psychosocial services provided by a mobile multi- disciplinary treatment team that includes case/care management, psychiatric services, counseling/psychotherapy, housing support, Substance Use Disorders treatment, and employment and rehabilitative services provided in the beneficiary’s home or community. ACT is an individually tailored combination of services and supports that may vary in intensity over time and is based on individual need. ACT includes availability of multiple daily contacts and 24-hour, 7-days- per-week crisis availability provided by the multi-disciplinary ACT team.

Intensive outpatient services are available for SUD-only conditions which includes individual assessment, individual treatment planning, individual therapy, group therapy, family therapy, crisis intervention, referral/linking/coordinating/management of services, peer recovery and recovery support, compliance monitoring, early intervention, detoxification/withdrawal monitoring, pharmacological supports and substance abuse treatment services. Level of care is determined by ASAM criteria.

Limits: Program limitations are based on medical necessity.

6.3.2.9- BH Psychosocial rehabilitation Provided for: Mental Health Substance Use Disorder

Psychosocial rehabilitation services description: A Clubhouse is a community-based program organized to support individuals living with mental illness. Clubhouse programs are appropriate for adults with a serious mental illness who wish to participate in a structured community with staff and peers and who desire to work on the goal areas reflected in the Core Psychiatric Rehabilitation Components. Club houses are vibrant, dynamic communities where meaningful work opportunities drive the need for member participation, thereby creating an environment where

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

Effective Date: October 1, 2020

Approval Date: 35 empowerment, relationship-building, skill development and related competencies are gained. Services are available for mental health diagnosis with co-occuring SUD.

Limits: Service limitations are based on medical necessity.

Guidance: If the state considers day treatment and partial hospitalization to be the same benefit, please indicate that in the benefit description. If there are differences between these benefits, such as the staffing or intensity of the setting, please specify those in the description of the benefit’s amount, duration, and scope.

6.3.3- BH Day Treatment Provided for: Mental Health Substance Use Disorder

Day treatment services description: Mental health and developmental disabilities day program sites are defined as places other than the beneficiary’s/family’s home, nursing facility, or a specialized residential setting where an array of mental health or developmental disability services and supports are provided to assist the beneficiary in achieving goals of independence, integrated employment and/or community inclusion, as specified in his individual plan of services.

For SUD-only conditions, the state provides equivalent services through intensive outpatient services and is described in 6.3.2.8.

Limits: Services limitations are based on medical necessity.

6.3.3.1- BH Partial Hospitalization Provided for: Mental Health Substance Use Disorder

Partial hospitalization services description: Partial hospitalization services may be used to treat a person with mental illness who requires intensive, highly coordinated, multi-modal ambulatory care with active psychiatric supervision. Treatment, services and supports are provided for six or more hours per day, five days a week. The use of partial hospitalization as a setting of care presumes that the beneficiary does not currently need treatment in a 24-hour protective environment. Coverage is dependent upon individual need for ongoing intensive active treatment and active psychiatric supervision services based on the medically necessary level of care.

Partial hospitalization services are available for SUD-only conditions.

6.3.4- BH

Inpatient services, including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Sections 2110(a)(10) and 2110(a)(18)) Provided for: Mental Health Substance Use Disorder

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

Effective Date: October 1, 2020

Approval Date: 36 Inpatient services description: Treatment within an inpatient psychiatric setting is directed at stabilization of incapacitating signs or symptoms, amelioration of severely disabling functional impairments, arrestment of potentially life-threatening self/other harm inclinations, management of adverse biologic reactions to treatment and/or regulation of complicated medication situations. Inpatient psychiatric care may be used to treat a person with mental illness who requires care in a 24-hour medically structured and supervised facility. The Severity of Illness/Intensity of Service clinical criteria for admission are based upon the assumption that the beneficiary is displaying signs and symptoms of a serious psychiatric disorder, demonstrating functional impairments, and manifesting a level of clinical instability (risk) that, either individually or collectively, are of such severity that treatment in an alternative setting would be unsafe or ineffective. Coverage is dependent upon active treatment being provided at the medically necessary level of care. The continuing stay recertification process is designed to assess the efficacy of the treatment regime in addressing these concerns, and to determine whether the inpatient setting remains the most appropriate, least restrictive, level of care for treatment of the beneficiary’s problems and dysfunctions.

Inpatient services are available for SUD-only conditions.

Guidance: If applicable, please clarify any differences within the residential treatment benefit (e.g. intensity of services, provider types, or settings in which the residential treatment services are provided).

6.3.4.1- BH Residential Treatment Provided for: Mental Health Substance Use Disorder

Residential treatment services description: Residential Treatment is defined as intensive therapeutic service which includes overnight stay and planned therapeutic, rehabilitative, or didactic counseling to address cognitive and behavioral impairments for the purpose of enabling the beneficiary to participate and benefit from less intensive treatment. A program director is responsible for the overall management of the clinical program, and treatment is provided by appropriate credentialed professional staff, including substance abuse specialists. Residential treatment must be staffed 24-hours-per-day. The clinical program must be provided under the supervision of Substance Abuse Treatment Specialists.

Limits: Service limitations are based on medical necessity.

6.3.4.2- BH Detoxification Provided for: Substance Use Disorder

Detoxification services description: Acute medical detoxification services are covered

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

Effective Date: October 1, 2020

Approval Date: 37 when medically necessary. Sub-acute detoxification is defined as supervised care for the purpose of managing the effects of withdrawal from alcohol and/or other drugs as part of a planned sequence of addiction treatment. Detoxification is limited to the stabilization of the medical effects of the withdrawal and to the referral to necessary ongoing treatment and/or support services. Sub-acute detoxification is part of a continuum of care for substance use disorders and does not constitute the end goal in the treatment process. The detoxification process consists of three essential components: evaluation, stabilization, and fostering client readiness for, and entry into, treatment. Detoxification can take place in both residential and outpatient settings, and at various levels of intensity within these settings. Client placement to setting and to level of intensity must be based on ASAM Criteria and individualized determination of client need. Sub-acute detoxification settings and levels of intensity correspond to the LOC determination based on the ASAM Criteria. This service is limited to stabilization of the medical effects of the withdrawal, and referral to necessary ongoing treatment and/or support services. This service, when clinically indicated, is an alternative to acute medical care provided by licensed health care professionals in a hospital setting.

Guidance: Crisis intervention and stabilization could include services such as mobile crisis, or short term residential or other facility-based services in order to avoid inpatient hospitalization.

6.3.5- BH Emergency services Provided for: Mental Health Substance Use Disorder

Emergency services description: Emergency services are covered including the screening and stabilization of a psychiatric emergency and does not require prior authorization.

Emergency services are available for SUD-only conditions.

6.3.5.1- BH Crisis Intervention and Stabilization Provided for: Mental Health Substance Use Disorder

Crisis intervention and stabilization services description: Crisis Intervention are unscheduled activities conducted for the purpose of resolving a crisis situation requiring immediate attention. Activities include crisis response, crisis line, assessment, referral, and direct therapy. The standard for whether a crisis exists is a "prudent layperson" standard. That means that a prudent layperson would be able to determine from the beneficiary’s symptoms that crisis services are necessary. Intensive crisis stabilization services are structured treatment and support activities provided by a multidisciplinary team and designed to provide a short-term alternative to inpatient psychiatric services. Services may be used to avert a psychiatric admission

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

Effective Date: October 1, 2020

Approval Date: 38 or to shorten the length of an inpatient stay when clinically indicated. Intensive crisis stabilization services are structured treatment and support activities provided by a mobile intensive crisis stabilization team that are designed to promptly address a crisis situation in order to avert a psychiatric admission or other out of home placement or to maintain a child or youth in their home or present living arrangement who has recently returned from a psychiatric hospitalization or other out of home placement. These services must be available to children or youth with serious emotional disturbance (SED) and/or intellectual/developmental disabilities (I/DD), including autism, or co- occurring SED and substance use disorder (SUD).

6.3.6- BH Continuing care services Provided for: Mental Health Substance Use Disorder

Continuing care services description: Referral/Linking/Coordinating/Management of SUD Services: Service purpose is in ensuring follow through with identified providers, providing additional support in the community if primary services are to be provided in an office setting, addressing other needs identified as part of the assessment and/or establishing the beneficiary with another provider and/or level of care. This service may be provided individually or in conjunction with other services based on the needs of the beneficiary (frequently referred to as substance use disorder case management). Services of compliance monitory identifying abstinence or relapse when it is a part of the treatment plan or an identified part of the treatment program and intervention services aimed at addressing problems/issues that may arise during SUD treatment and could result in the beneficiary requiring a higher level of care if intervention is not provided.

For SUD-only conditions, the state provides equivalent services through peer support as described in 6.3.2.4.

6.3.7- BH Care Coordination Provided for: Mental Health Substance Use Disorder

Care coordination services description: Supports and service coordination for women with mental health or co-occurring sud conditions, which includes a designated coordinator/case worker to assist with planning and/or facilitating planning using person-centered principles, developing an individual plan of service using the person- centered planning process, linking to, coordinating with, follow-up of, advocacy with, and/or monitoring of Specialty Services and Supports and other community services/supports. Brokering of providers of services/supports, assistance with access to entitlements and/or legal representation, coordination with health care providers.

For SUD-only conditions, the state provides identical care coordination services

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

Effective Date: October 1, 2020

Approval Date: 39 through the case management benefit described in 6.3.8-bh; however, the funding source for women with SUD-only conditions is through a SAMHSA Substance Abuse Block Grant.

Limits: Service limitations are based on medical necessity.

6.3.7.1- BH Intensive wraparound Provided for: Mental Health Substance Use Disorder

Intensive wraparound services description: Wraparound utilizes a Child and Family Team, with team members determined by the family often representing multiple agencies and informal supports. The collaborative team planning process that focuses on the unique strengths, values and preferences of the beneficiary and family and is developed in partnership with other community agencies. The Child and Family Team creates a highly individualized planning and a Wraparound plan with the beneficiary and family that consists of mental health specialty treatment, services and supports covered by the Medicaid mental health state plan, waivers, and other community services and supports. The Wraparound plan may also consist of other non-mental health services and supports that are secured from, and funded by, other agencies in the community. The Wraparound plan is the result of a collaborative team planning process. This planning process tends to work most effectively with beneficiaries and their families who, due to safety and other risk factors, require services from multiple systems and informal supports.

6.3.7.2- BH Care transition services Provided for: Mental Health Substance Use Disorder

Care transition services description: These services occur through Targeted Case Management, support services and wraparound services, which all can be used to address an individual’s transition to a community setting. Case-Management services will be made available for up to 180 consecutive days of a covered stay in a medical institution, which can be exceeded dependent upon medical necessity.

6.3.8- BH Case Management Provided for: Mental Health Substance Use Disorder

Case management services description: For women with mental health or co- occurring SUD conditions, targeted case management services are services furnished to assist individuals in gaining access to needed medical, social, educational, care transition and other services. Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social, or other services. Development (and periodic revision) of a specific person-centered care plan

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

Effective Date: October 1, 2020

Approval Date: 40 that is based on the information collected through the assessment that specifies the goals and actions to address service needs, linking/coordination of services, monitoring and follow-up of services, and reassessment of the beneficiary’s status and need.

For those receiving SUD services only, case management as described above, is covered by a SAMHSA Substance Abuse Block Grant.

Limits: Service limitation are based on medical necessity.

6.3.9- BH Other Provided for: Mental Health Substance Use Disorder

The state of Michigan has two Health Home SPAs, the Opioid Health Home (OHH) and the Behavioral Health Home (BHH). These are services authorized under Section 1945 of the US Social Security Act that provide intensive care management, family/social support, care transitions, etc., in an integrated care setting in select Prepaid Inpatient Health Plan Regions. Beneficiaries in select regions qualify if they meet diagnostic criteria—for BHH, this is a select Serious Mental Illness/Serious Emotional Disturbance; for OHH, this is an Opioid Use Disorder. The relevant SPAs are #20-1500 (BHH) and #20-1501 (OHH).

6.4- BH Assessment Tools

6.4.1- BH Please specify or describe all of the tool(s) required by the state and/or each managed care entity:

ASAM Criteria (American Society Addiction Medicine) Mental Health Substance Use Disorders

InterQual Mental Health Substance Use Disorders

MCG Care Guidelines Mental Health Substance Use Disorders

CALOCUS/LOCUS (Child and Adolescent Level of Care Utilization System)

Mental Health Substance Use Disorders

CASII (Child and Adolescent Service Intensity Instrument) Mental Health Substance Use Disorders

CANS (Child and Adolescent Needs and Strengths)

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

Effective Date: October 1, 2020

Approval Date: 41 Mental Health Substance Use Disorders

State-specific criteria (e.g. state law or policies) (please describe) Mental Health Substance Use Disorders

Plan-specific criteria (please describe) Mental Health Substance Use Disorders

Other (please describe) Mental Health Substance Use Disorders

Other Valid Instruments may include any of the following specific to each individual’s condition: Devereux Early Childhood Assessment (DECA), Child and Adolescent Functional Assessment Scale (CAFAS®) or the Preschool and Early Childhood Functional Assessment Scale (PECFAS®), Global Assessment of Functioning (GAF) Supports Intensity Scale (SIS)-A, SIS-C, the Global Appraisal of Individual Needs Initial (GAIN-I). The PIHPs network will utilize standardized instruments to assist in identifying level of need (i.e. LOCUS, SIS, ASAM, Gain-I0), administer other face to face assessments related to the individual’s functional abilities (i.e. Essentials For Living/ELF, Functional Behavioral Assessment/FBA, other adaptive behavior/global functioning scales, etc.), and identify services and supports required to reach the expected outcomes of community inclusion and participation.

The state updates its Medicaid provider manual on a quarterly basis. Medicaid provider bulletins and L-letters are utilized as needed. L-letters are informational letters that are distributed to Medicaid enrolled providers on an as needed basis. Examples of when bulletins and L-letters are used include new or changes to existing policy, updates to evidence-based guidelines, changes to validated screening/assessment tools, or to provide information about public health emergencies such as disease outbreaks. Medicaid enrolled providers can subscribe to receive all Medicaid program updates or program specific updates via email from the Michigan Department of Health and Human Services.

No specific criteria or tools are required Mental Health Substance Use Disorders

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools to determine possible treatments or plans of care, providing education, training, and technical resources, and covering the costs of administering or purchasing the assessment tools.

6.4.2- BH Please describe the state’s strategy to facilitate the use of validated assessment tools for the treatment of behavioral health conditions.

State strategy to facilitate the use of validated assessment tools for the treatment of behavioral

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

Effective Date: October 1, 2020

Approval Date: 42 health conditions: The state Medicaid agency exercises administrative discretion in the administration and supervision of the State plan benefits and issues policies, rules and regulations related to the State plan benefit assessment tools. These assessment tools are included in our managed care contract and required by all of Michigan’s Prepaid Inpatient Health Plans. The State plan eligibility criteria, enrollment, and eligibility determination must include evidence of any instrument(s)/validated tools used to make this determination as described in Medicaid policy, contract, and are reviewed periodically by the state/PIHP and external quality review (EQR) vendors. The state updates its Medicaid provider manual on a quarterly basis. Medicaid provider bulletins and L-letters are utilized as needed. L-letters are informational letters that are distributed to Medicaid enrolled providers on an as needed basis. Examples of when bulletins and L-letters are used include new or changes to existing policy, updates to evidence-based guidelines, changes to validated screening/assessment tools, or to provide information about public health emergencies such as disease outbreaks. Medicaid enrolled providers can subscribe to receive all Medicaid program updates or program specific updates via email from the Michigan Department of Health and Human Services.

The state’s Behavioral Health and Developmental Disabilities Administration (BHDDA) plans and implements required provider training for new mandatory validated tools. BHDDA provides a letter of training notification to executive directors of prepaid inpatient health plans (PIHPS) and substance abuse prevention and treatment directors. The notification provides training timelines and requests that each PIHP designate a representative that works with a BHDDA staff person to implement the training process.

6.2.5- BH Covered Benefits The State assures the following related to the provision of behavioral health benefits in CHIP:

All behavioral health benefits are provided in a culturally and linguistically appropriate manner consistent with the requirements of section 2103(c)(6), regardless of delivery system.

The state will provide all behavioral health benefits consistent with 42 CFR 457.495 to ensure there are procedures in place to access covered services as well as appropriate and timely treatment and monitoring of children with chronic, complex or serious conditions.

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

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

Effective Date: October 1, 2020

Approval Date: 43

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes No Guidance: If the State does not provide any mental health or substance use disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)). Continue on to Section 6.3.

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

6.3.1. X The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2. ∼ The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre- existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and(3)) (42 CFR 457.1005 and 457.1010)

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

Effective Date: October 1, 2020

Approval Date: 44

6.4.1.

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

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

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

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

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

Effective Date: October 1, 2020

Approval Date: 45 6.4.2. ∼ Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low-income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a)) 6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3. The state assures that the coverage for the family otherwise

meets title XXI requirements. (42CFR 457.1010(c))

Section 7. Quality and Appropriateness of Care

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

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

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1. Ξ Quality standards 7.1.2. Ξ Performance measurement 7.1.3. Ξ Information strategies 7.1.4. Ξ Quality improvement strategies

State Response: The State plans to assure the quality and appropriateness of care, particularly with respect to prenatal care and labor and delivery of the unborn child. Health Maintenance Organizations (Public Act 1978, No. 368 or Michigan Compiled Laws 333.21001)

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

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

Effective Date: October 1, 2020

Approval Date: 46

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

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

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

State Response:

Section 8. Cost Sharing and Payment (Section 2103(e))

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

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

8.1.1. YES 8.1.2. X NO, skip to question 8.8.

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

8.2.1. Premiums:

8.2.2. Deductibles:

State Response: Michigan will assess no deductibles.

8.2.3. Coinsurance or co-payments:

8.2.4. Other: None 8.3. Describe how the public will be notified, including the public schedule, of this cost- sharing (including the cumulative maximum) and changes to these amounts and any

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

Effective Date: October 1, 2020

Approval Date: 47 differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

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

8.4.1. Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2. No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3 No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

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

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

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