Department of Health & Human Services Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519 Stephen Fitton, Director Medical Services Administration Federal Liaison Unit MAR 0 9 2010 Michigan Department of Community Health 400 South Pine Lansing, Michigan 48933 ATTN: Nancy Bishop Dear Mr. Fitton: CAIS CENTERS for MEDICARE & MEDICAID SERVICES Enclosed for your records is an approved copy of the following State Plan Amendment: ~ Transmittal #09-03 Patient pay amounts for purchase of non-covered services. This SP A proposes to place reasonable limits on the amounts of incurred necessary medical and remedial care expenses recognized under State law, but not covered under the State Plan. ~ Effective July 1, 2009 Please be aware that when the State submits a State Plan Amendment or waiver proposal, waiver renewal, waiver extension or waiver amendment that may impact Indians or Indian health providers, CMS will look for evidence that the State consulted with the tribes and Indian health providers in the State prior to submission of the change to the Medicaid or CHIP program, pursuant to section 1902(a)(73) of the Act added by section 5006(e) of the Recovery and Reinvestment Act of2009. This consultation must include all federally recognized tribes and Indian health providers within the State. Indian health providers include the Indian Health Service, Tribal health programs operating under P.L. 93-638 and Urban Indian organizations within the State. If you have any questions, please contact Leslie Campbell at (3 I 2) 353-1557 or Leslie.Campbell@cms.hhs.gov . Associate Re ional Administrator Division of Medicaid & Children's Health Operations Enclosure

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTHCARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

7 TRANSMITTAL NUMBER: 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF 09- 03 Michigan STATE PLAN MATERIAL 3, PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL FOR: HEALTH CARE FINANCING ADMINISTRATION SECURITY ACT (MEDICAID)

REGIONAL ADMINISTRATOR HEALTH FINANCING ADMINISTRATION DEPARTMENT OF HUMAN SERVICES

TO:

4. PROPOSED EFFECTIVE DATE July 1, 2009

5. TYPE OF PLAN MATERIAL (Check One):

(1 NEW STATE PLAN

(1) AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 435.725(d)

7. FEDERAL BUDGET IMPACT: a. FFY 09 $ -0- b. FFY 10 $ -0-

. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

8 Livementto Attachment 2.6-A, page 1

Supplement 3

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

Supplement to Attachment 2.6-A, page 1

10. SUBJECT OF AMENDMENT: Patient pay amounts for purchase of non-covered services

411. GOVERNOR'S REVIEW (Check One):

(1) GOVERNOR'S OFFICE REPORTED NO COMMENT (.) COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

(_NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[K) OTHER, AS SPECIFIED: Paul Reinhart, Director Medical Services Administration

12. —_ OF _ AGENCY OFFICIAL: 1 7

Stephen Fitton

14. TITLE: Acting Director, Medical Services Administration

15. DATE SUBMITTED: September 2, 2009

16. RETURN TO:

Medical Services Administration

Program/Eligibility Policy Division - Federal Liaison Unit Capitol Commons Center - 7” Floor

400 South Pine

Lansing, Michigan 48933

Attn: Nancy Bishop

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

September 2, 2009

18 DATE APPROVED:

MAR 0 9 2010

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: REGIONAL OFFICIAL: July 1, 2009 21. TYPE NAME: 22. E: Verlon Johnson Associa’ Regional Administrator 23. REMARKS:

FORM HCFA-179(07-92)

Instructions on Back

Supplement 3 to Attachment 2.6-A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of MICHIGAN

Reasonable Limits on Amounts for Necessary Medical or Remedial Care not Covered under Medicaid

Reasonable and necessary medical expenses not covered by Medicaid, incurred in the 3 month period prior to the month of application are allowable deductions. Expenses incurred prior to this three month period are not allowable deductions.

Medical and remedial expenses incurred as the result of imposition of a transfer of asset penalty period are limited to zero, unless application of these limits would result in undue hardship.

An undue hardship exists when the beneficiary’s physician (M.D. or D.O.) says necessary medical care is not being provided and the client needs treatment for an emergency condition.

TN NO.: 09-03 Approval Date: MAR 0 9 2010 Effective Date: 07/01/2009

Supersedes TN No.: 91-36

Department of Health & Human Services CII. AY Centers for Medicare & Medicaid Services

233 North Michigan Avenue, Suite 600

Chicago, Illinois 60601-5519 CENTERS for MEDICARE & MEDICAID SERVICES

JAN 10 2012

Stephen Fitton, Medicaid Director

Medical Services Administration

Federal Liaison Unit

Michigan Department of Community Health 400 South Pine

Lansing, Michigan 48933

ATTN: Loni Hackney Dear Mr. Fitton: Enclosed for your records is an approved copy of the following State Plan Amendment:

> Transmittal #11-013: Exception to the Medicaid RAC implementation date > Effective Date: March 31, 2012

If you have any questions, please contact Leslie Campbell at (312) 353-1557 or Leslie. Campbell@cms.hhs.gov.

Sincerely,

Verlon John: Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosure

DEPARTMENT OF HEAL TH AND HUMAN SERVICES HEALTHCARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER: 1 1 - 13 3. PROGRAM IDENTIFICATION: FORM APPROVED OMB NO 0938-0193 2. STATE: Michigan FOR: HEALTH CARE FINANCING ADMINISTRATION TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEAL TH FINANCING ADMINISTRATION DEPARTMENT OF HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 4. PROPOSED EFFECTIVE DATE March 31, 2012 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN t8] AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Section 1902(a)(1) of SSA a. FFY 2012 $ o _____ _ 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: General Program Administration, Page 36a of Section 4.5(a)(1) 10. SUBJECT OF AMENDMENT: b. FFY 2013 $ 0 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): General Program Administration, Page 36a of Section 4.5(a)(1) This amendment requests an exception to the Medicaid RAC January 1, 2012 implementation date published in CMS' September 16, 2011 final rule. The State proposes to implement its program by March 31, 2012. 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED t8] OTHER, AS SPECIFIED: 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Stephen Fitton, Director Medical Services Administration NCY OFFICIAL: 16. RETURN TO: ------------1 Medical Services Administration 13. Stephen Fitton Actuarial Division -----------------------i Capitol Commons Center - 7th Floor 14. TITLE: 400 South Pine Street Director, Medical Services Administration Lansing, Michigan 48933 15. DATE SUBMITTED: November 30, 2011 Attn: Loni Hackney FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: i ? II JAN 1'02012 18 DATE APPROVED: PLAN APPROVED - ONE C 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SI 31 /7- hnson Associate FORM HCFA-179(07-92) Instructions on Back

Revision: HCFA-PM-88-10 SEPTEMBER 1988 State:

36a (BERC)

MICHIGAN

Citation

4.5(a)(1)

Section X

1902(a)(42)(B)(i) of the Social Security Act

Section &

1902(a)(42)(B)(ii)(1) of the Act

Section 1902 |

(a)(42)(B)(ii)(II)(aa) of the Act

Medicaid Recovery Audit Contractor Program

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

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

CMS' SEPTEMBER 16, 2011, PUBLICATION OF THE MEDICAID RAC FINAL RULE DOES NOT PROVIDE SUFFICIENT TIME FOR THE STATE TO COMPLETE ITS PROCUREMENT PROCESS AND IMPLEMENT THE PROGRAM BY JANUARY 1, 2012. THE STATE PROPOSES AN IMPLEMENTATION DATE OF MARCH 31, 2012.

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

Place a check mark to provide assurance of the following: KI The State will make payments to the RAC(s) only from amounts recovered.

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

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

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

[1 The State attests that the contingency fee rate paid to the Medicaid RAC will exceed the highest rate paid to Medicare RACs, as published in the Federal Register. The State will only submit for FFP up to the amount equivalent to that published rate.

(1 The contingency fee rate paid to the Medicaid RAC that will exceed the highest rate paid to Medicare RACs, as published in the Federal Register. The State will submit a justification for that rate and will submit for FFP for the full amount of the contingency fee.

TN NO.: 11-13 Approval Date: YAN 102012 effective Date: 03/31/2012

Supersedes TN No.: 10-23

Department of Health & Human Services CAA Centers for Medicare & Medicaid Services

233 North Michigan Avenue, Suite 600

Chicago, Illinois 60601-5519 CENTERS for MEDICARE & MEDICAID SERVICES

July 12, 2012

Stephen Fitton, Medicaid Director

Medical Services Administration

Federal Liaison Unit

Michigan Department of Community Health 400 South Pine

Lansing, Michigan 48933

ATTN: Loni Hackney Dear Mr. Fitton: Enclosed for your records is an approved copy of the following State Plan Amendment:

> Transmittal #11-014: Physician Adjuster Program >» Effective Date: July 1, 2012

If you have any questions, please contact Leslie Campbell at (312) 353-1557 or Leslie.Campbell@cms.hhs.gov.

Sincerely,

Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosure

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTHCARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF

STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION

41. TRANSMITTAL NUMBER: 2. STATE:

14-14 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

Michigan

TO: REGIONAL ADMINISTRATOR HEALTH FINANCING ADMINISTRATION

DEPARTMENT OF HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE July 1, 2012

5. TYPE OF PLAN MATERIAL (Check One):

(NEW STATE PLAN

[] AMENDMENT TO BE CONSIDERED AS NEW PLAN

EK) AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 447 Subpart B

7. FEDERAL BUDGET IMPACT: a. FFY 2012 $ 0. b. FFY 2013 $0

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-B, Page 1a

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT ((f Applicable):

Attachment 4.19-B, Page 1a

10. SUBJECT OF AMENDMENT:

This amendment is to add Western Michigan University to the Physician Adjuster Program.

11. GOVERNOR'S REVIEW (Check One):

L] GOVERNOR'S OFFICE REPORTED NO COMMENT [.] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED

L] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

KX] OTHER, AS SPECIFIED: Stephen Fitton, Director Medical Services Administration

12. SI NCY OFFICIAL: 13. TY! :

Stephen Fitton

14. TITLE: Director, Medical Services Administration

15. DATE SUBMITTED: December 22, 2011

16. RETURN TO:

Medical Services Administration Actuarial Division

Capitol Commons Center - 7th Floor 400 South Pine Street

Lansing, Michigan 48933

Attn: Loni Hackney

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: 48 DATE APPROVED: December 22, 2011 JUL 12 202 PLAN APPROVED ~ ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. ONAL OFFICIAL:

July 1, 2012

21. TYPE NAME: 22. . Verlon Johnson Associa Regional Administrator 23. REMARKS:

FORM HCFA-179(07-92)

Instructions on Back

Attachment 4.19-B Page 1a

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of MICHIGAN

Policy and Methods for Establishing Payment Rates (Other than Inpatient Hospital and Long Term Care Facilities)

e the provider's usual and customary charge minus any third party payments, contractual adjustments, and any applicable Medicaid co-payment, patient pay, or spend-down amounts.

A provider's customary charge refers to the amount which the individual practitioner charges in the majority of cases for a specific medical procedure exclusive of token charges for charity patients and substandard charges for welfare and other low income patients.

Payment adjustments will be made for practitioner services provided through the following public entities:

University of Michigan Health System Wayne State University

Hurley Hospital

Michigan State University

Oakland University

WESTERN MICHIGAN UNIVERSITY

Adjustments apply to dates of service on or after April 1, 2006. Beginning January 1, 2011, Oakland University will be eligible for pricing adjustments under this program. BEGINNING JULY 41, 2012, WESTERN MICHIGAN UNIVERSITY WILL BE ELIGIBLE FOR PRICING ADJUSTMENTS UNDER THIS PROGRAM. Eligibility for these adjustments is limited to individual practitioners or practitioner groups designated by the public entities. Service provided by the following practitioners, when not included in facility payments to the public entity, are included:

Physicians (MD and DO) Ophthalmologists

Oral Surgeons

Dentists

Podiatrists

Physician's Assistants

Nurse Practitioners

Certified Nurse Midwives

Certified Registered Nurse Anesthetists Certified Anesthesiologist Assistants Optometrists

Adjustments apply to both public and private practitioners and practitioner groups. Practitioners and practitioner groups are either employees of the public entity or are under a contract with the public entity. All services eligible for the payment adjustment are billed under the federal employer number of the public entity or under the employer identification number of the practitioner/practitioner group. Billings are submitted by the public entity or by the practitioners/ practitioner groups. The Medical Services Administration must concur with the public entity's designations in order for the payment adjustment to be applied.

TN NO.: 14-14 Approval Date._ SUL 1:2 2012 Effective Date: 07/01/2012

Supersedes TN No.:_ 10-21

Table of Contents State/Territory Name: MI State Plan Amendment (SPA) #: 13-0016 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SP A Pages

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

Chicago Regional Office

233 N. Michigan

Suite 600

Chicago, Illinois 60601

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

August 11, 2016

Chris Priest

Medical Services Administration

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

Lansing, Michigan 48909-7979

ATTN: Erin Black

Dear Mr. Priest:

Enclosed for your records is an approved copy of the following State Plan Amendment:

> Transmittal #: 13-0016 Cost Sharing > Effective Date: January 1, 2014

If you have any questions, please contact Keri Toback at (312) 353-1754 or keri.toback(@cms.hhs.gov.

Sincerely,

/s/ Ruth A. Hughes Associate Regional Administrator Division of Medicaid & Children’s Health Operations

cc: Erin Black, MDHHS

Medicaid Premiums and Cost Sharing: Summary Page (CMS 179)

State/Territory name: Transmittal Number:

Michigan

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-13-0016

Proposed Effective Date 01/01/2014

Federal Statute/Regulation Citation

(mn/dd/yyyy)

[42 CFR 447.56

Federal Budget Impact

Federal Fiscal Year

First Year Second Year [2015 _

Subject of Amendment

Amount

$}62000.00 s|83000.00

This State Plan Amendment (SPA) is being submitted to exempt certain groups from Medicaid Copayment responsibilities. The original submission date was 12/30/13. In addition, the SPA addresses general cost sharing provisions. Note that the effective date for some provisions may be different from that proposed above and, if

so, the date is noted within the template.

Governor's Office Review

Governor's office reported no comment

Comments of Governor's office received

Describe:

No reply received within 45 days of submittal

® Other, as specified Describe: Chris Priest, Director

Medical Services Administration

Michigan Department of Community Health

Signature of State Agency Official Submitted By:

Last Revision Date: Submit Date:

Erin Black Aug 10, 2016 May 17, 2016

DATE RECEIVED: May 17, 2016

DATE APPROVED: August 11, 2016

PLAN APPROVED — ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL: January 1, 2014

/s/

SIGNATURE OF REGIONAL OFFICIAL:

TYPED NAME: Ruth A. Hughes

TITLE: Associate Regional Administrator

REMARKS:

Approval Date: 8/11/16 Effective Date: 1/01/2014 TN No: MI-13-0016 Michigan

Medicaid Premiums and Cost Sharing E Determine that the alternative provider can provide services to the individual in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing if the individual is otherwise exempt from cost sharing;and E Provide a referral to coordinate scheduling for treatment by the alternative provider. [Z] The state assures that it has a process in place to identify hospital emergency department services as non-emergency for purposes of imposing cost sharing. This process does not limit a hospital's obligations for screening and stabilizing treatment of an emergency medical condition under section 1867 of the Act; or modify any obligations under either state or federal standards relating to the application of a prudent-layperson standard for payment or coverage of emergency medical services by any managed care organization. The process for identifying emergency department services as non-emergency for purposes of imposing cost sharing is:. The State defines non-emergency services consistent with 42 CFR 447.51, as it refers to 42 CFR 438.114 and the prudent layperson standard. With respect to cost-sharing, the State incorporates the requirements of 42 CFR 447.54 into its guidance to providers regarding imposing cost-sharing in the hospital emergency department. The State defers to the medical judgment of health care professionals for determining what is and is not a condition that requires emergency treatment. The Stale expects that hospitals providing emergency department services develop cost•sharing and referral policies and procedures that are consistent with the nbove regulatory requirements nnd existing policy. In Michigan, the vast majority of beneficiaries are enrolled in Managed Care Organizations (MCOs). Enrollment in an MCO requires the beneficiary to choose or be assigned a Primary Care Provider (PCP). The State's contracted MCOs are also required to operate clinically supponed toll-free assistance lines 24 hours per day, which may facilitate referrals or assist with care coordination with the beneficiary's assigned PCP. Hospitals may also refer beneficiaries to nearby Federally Qualified Health Centers or Rural Health Clinics, as the State has n robust network of these providers and many offer extended hours and can accommodate timely follow-up for non-emergency care. The State will perform outpatient post•payment reviews per published Medicaid hospital policy lo assess provider compliance with the requirements. Beneficiaries may call the beneficiary help line and submit a beneficiary complaint form to report any inappropriate charges for cost sharing. All complaints received are investigated. Upon completion of an investigation, a response is mailed to the beneficiary that includes the findings of the investigation, the beneficiary's hearing rights and how the beneficiary can request an administrative hearing before an administrative law judge if they do not agree with the findings of the investigation. Cost Sharing for Drugs The state charges cost sharing for drugs. The state has established differential cost sharing for preferred and non-preferred drugs. E l11e slate identifies which drugs are considered to be non-preferred. [Z] The state assures that it has a timely process in place to limit cost sharing to the amount imposed for a preferred drug in the case of a non-preferred drug within a therapeutically equivalent or similar class of drugs, if the individual's prescribing provider detennines that a preferred drug for treatment of the same condition either will be less effective for the individual, will have adverse effects for the individual, or both. In such cases, reimbursement to the phannacy is based on the appropriate cost sharing amount. Page 2 of 3

Approval Date: 8/11/16 Effective Date: 1/01/2014 TN No: MI-13-16 Michigan

Medicaid Premiums and Cost Sharing Beneficiary nnd Public Notice Requirements [ZJ Consistent with 42 CFR 447.57, the state makes available a public schedule describing current cost sharing requirements in a manner that ensures that affected applicants, beneficiaries and providers are likely to have access to the notice. Prior to submitting a SPA which establishes or substantially modifies existing cost sharing amounts or policies, the state provides the public with advance notice of the SP A, specifying the amount of cost sharing and who is subject to the charges, and provides reasonable opportunity for stakeholder comment. Documentation demonstrating that the notice requirements have been met are submitted with the SPA. The state also provides opportunity for additional public notice if cost sharing is substantially modified during the SPA approval process. Other Relevant Information PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938, I I 48. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the infonnation collection. If you have comments concerning the accuracy of the time estimale(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 201,10415 Page 3 of3 Approval Date: 8/11/16 Effective Date: 1/01/2014 TN No: MI-13-16 Michigan

Approval Date: 8/11/16 Effective Date: 1/01/2014 TN No: MI-13-16 Michigan

Approval Date: 8/11/16 Effective Date: 1/01/2014 TN No: MI-13-16 Michigan

Approval Date: 8/11/16 Effective Date: 1/01/2014 TN No: MI-13-16 Michigan

Approval Date: 8/11/16 Effective Date: 1/01/2014 TN No: MI-13-16 Michigan

Approval Date: 8/11/16 Effective Date: 1/01/2014 TN No: MI-13-16 Michigan

Approval Date: 8/11/16 Effective Date: 1/01/2014 TN No: MI-13-16 Michigan

Approval Date: 8/11/16 Effective Date: 1/01/2014 TN No: MI-13-16 Michigan

Approval Date: 8/11/16 Effective Date: 1/01/2014 TN No: MI-13-16 Michigan

TN No: MI-13-16 Approval Date: 8/11/16 s Effective Date: 1/01/2014

TN No: MI-13-16 Approval Date: 8/11/16 Effective Date: 1/01/2014

Revision: HCFA-AT-91-4 (BPD) Page 54 August 1991

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN RESERVED Citation 448 62 SER AAT Sth A 58 fe 434+6ta}anc-tbrelthe Ast (b) TN NO.: 13-16 Approval Date: _ 8/11/16 Effective Date: 01/01/2014 Supersedes

TN No.: 03-13

Revision; HCFA-PM-91-4 (BPD) Page 55 August 1991

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN

RESERVED

TN NO.: 13-16 Approval Date: __8/11/16 Effective Date; 01/01/2014

Supersedes TN No.: 03-13

Revision: HCFA-PM-91-4 (BPD) August 1991 Page 56 0MB No: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of MICHIGAN RESERVED 42 CFR 447.51 lhru 447.48 TN NO.: 13-16 Supersedes TN No.: 92-01 (Continued) (3) UAless a wai1Jer 1,mder 42 CFR 431 .55(g) applies, AemiAal deductible, coinsurance, Gepayment, er similar charges are imposed for seP.•ices that are not exch:1ded from such charges uneler ilem (b) (2) abo¥e. D Not applicable. No such charges are imposes. (i) i;:or any se1Vice, no more lhan one type of oharge is imposed. (ii) Charges apply to services furnisheel to the following age groups: D 18 or oleler 0 19 OF older D 20 oFolder 18] 21 or older D Charges apply te services furnished to the following reasonable categories of indi1Jid1:1als listed below who are 18 years of age oF oĤl under the age 21. Approval Date: 8/11/16 Effective Date: 01/01/14 HCFA ID: 7982E

Revision: HCFA-PM-91-4 (BPD) Page 56a August 1991 OMB No: 0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN RESERVED Citation S26FR444 54th 44 88 TN NO.: 13-16 Approval Date: __ 8/11/16 Effective Date: 01/01/14 Supersedes

TN No.: 92-01 HCFA ID: 7982E

Revision: HCFA-PM-91-4 (BPD) Page 56c August 1991 OMB No; 0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of MICHIGAN

RESERVED Citation 4,48(6) SdUndividuale-are-covered-ac-medically needy

TN NO.: 13-16 Approval Date: _ 8/11/16 Effective Date: 01/01/14

Supersedes HCFA ID: 7982E TN No.: 92-01

Revision: HCFA-PM-91-4 (BPD) Page 56d August 1991 OMB No: 0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN RESERVED Citation 4-48{6)(2) (Continued) 62 CFR+44254 through 447.58 (Sectien-8505) 447.54-through-447.58 TN NO.: 413-46 Approval Date: _ 8/11/16 Effective Date: 01/01/14 Supersedes HCFA ID: 7982E

TN No.: 92-01

Revision: HCFA-PM-91-4 (BPD) Page 56e August 1991 OMB No: 0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of MICHIGAN

RESERVED

TN NO.: 13-16 Approval Date: _ 8/11/16 Effective Date: 01/01/14

Supersedes HCFA ID: 7982E TN No.: 92-01

Revision: HCFA-PM-91-4 (BPD) Page 56f August 1991 OMB No: 0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN

RESERVED

TN NO.: 13-16 Approval Date: __8/11/16 Effective Date: 01/01/14

Supersedes HCFA ID: 7982E TN No.: 92-01.

Attachment 4.18-A Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN

Cost Sharing and Similar Charges

A--The-following-charges-are-imposed-on-the categorically-and-medically- needy-for-services-other than-these-provided-under-section-4005-{a}{4}-through-{5}-

and-{7)-of the Act Servises-covered for.certain ambulatory beneficianes- Type Gharge Amauat- $27.00}. Dental-Senices x $3.00-per-each-reimbureable-visit-{average- payment $440.00}. Podiatre Services: x $2 00-per each reimbursable visit {average-payment $32.00). Hearing Aids * $3.00.0n-each-hearing-aid-{average-payment $340.00). Pharmacy-Services-Specified-by the Deparment x $1.00-4or each.generic drug (average payment $415.00) and- $3.00-for-each brand-drig (average payment $495.00)- dispensed— Chiropractic Services. x $4.00 for-each-reimbursable visit (average paymentis- $44.90). Physician Office Visit x $2.00-for-each reimbursable visit (average payment$35.00) payment-$70.00) \n-patient-Hespital x $50.00-for-the first-day-of each-reimbursable-inpatient- hospital-stay taverage payment $1265) TN NO.: 13-16 Approval Date: _ 8/11/16 Effective Date: 01-01-2014 Supersedes

TN No.: 05-14

Attachment 4.18-A Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of MICHIGAN

Charges Imposed on Categorically and Medically Needy

TN NO,: 13-16 Approval Date: 8/11/16 Effective Date: 01/01/14 Supersedes

TN No.; 04-06

Revision: HCFA-PM-85-14 (BERC) September 1985 Attachment 4.18-A

Page 3 OMB NO.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN

TN NO.: 13-16 Approval Date: 8/11/16 Effective Date: 01/01/14

Supersedes TN No.: 93-14 HCFA ID: 0053C/0061E

Revision: HCFA-PM-85-14 (BERC) September 1985

Attachment 4.18-C Page 1 OMB No: 0938-0193

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN

AThe folleowing-charges —are imposed—on the medically-needy-for services:

Sepices | Type Charge ss Bade Cain Capay ever is-$27-00- Dental-services. -to-recipi -24-and-over —x $3.00/each-reimbursable vist. The average- provided to recipients-age. payment for-serice-for-ecipients-age-24-and- over is $440.00-

Podiatric-services provided -to-recipients-age -21-and-over- =k $2-00/each -reimbursable visit. The average. payment for services for recipients-age 21-and- over is $32.

Hearing-aids provided te-recipients -age 21-and-over. od $3-00-GA-each-hearing-aid—The -average- and aver is $340.00-

Pharmacy services specified by-the DepaAmentfor-cenain- Sead $1-00/each prescriptionthe average payment

ambulatory -racipients age 21-and-over fer service for-recipients age 21 and overis-

GChiroprachs senices provided to-recipients 24-and-older Sead $1-00/each-reimbursable-visit:The average - payment for-semice for-recipients age 21-and- overis-$44-

TN NO.: 13-16 Approval Date: 8/11/16 Effective Date: 01-01-14 Supersedes HCFA ID: 0053C/0061E

TN No.: 93-21

Revision: HCFA-PM-85-14 (BERC) Attachment 4.18-C September 1985 Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN

TN NO.: 13-16 Approval Date: 8/11/16 Effective Date: 01/01/14 Supersedes HCFA ID: 0053C/0061E

TN No.: 85-27

Revisions: HCFA-PM-85-14 (BERC) Attachment 4,18-C September 1985 Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State of MICHIGAN

TN NO.: 13-16 Approval Date: 8/11/16 Effective Date: 01-01-14

Supersedes TN No.: 85-27

Table of Contents State/Territory Name: MI State Plan Amendment (SPA) #: 13-0100 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

February 3, 2014

Stephen Fitton, Medicaid Director Medical Services Administration Federal Liaison Unit Michigan Department of Community Health 400 South Pine Lansing, Michigan 48933

ATTN: Loni Hackney

Dear Mr. Fitton:

Enclosed for your records is an approved copy of the following State Plan Amendment:

 Transmittal: #13-0100 MAGI Groups  Effective: January 1, 2014

If you have any questions, please contact Leslie Campbell at (312) 353-1557 or Leslie.Campbell@cms.hhs.gov.

Sincerely,

/s/

Verlon Johnson

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Michigan 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.

13-0100 4M I

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

Citation. se nent nie ee 0)(A)Gi) and (ii); 1905(u)(2)(B); 1920; and 1931(b) and (d)

Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $0.00 — Second Year 2015 $ 0.00 Subject of Amendment

This amendment deals with the mandatory and optional eligibility groups in the Family/Adult category. These are the various eligibility groups the state is required to or may elect to cover under its Medicaid program.

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

No reply received within 45 days of submittal "@ Other, as specified

Describe:

Steven Fitton, Director

Medical Services Administration

Signature of State Agency Official

Submitted By: Loni Hackney

Last Revision Date: Jan 29, 2014

Submit Date: Oct 28, 2013 DATE RECEIVED: DATE APPROVED: October 28, 2013 February 3, 2014

PLAN APPROVED — ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL: SIGNATURE OF REGIONAL OFFICIAL: January 1, 2014 /s/ TYPED NAME: TITLE: Verlon Johnson Associate Regional Administrator REMARKS:

Enter the AFDC Standards below. All states must enter:

AFDC Payment Standard in Effect As of July 16, 1996

Entry of other standards is optional.

Medicaid Eligibility

MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and

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

The standard is as follows: C Statewide standard @ Standard varies by region C Standard varies by living arrangement C Standard varies in some other way Name of region Description Shelter Region | Shelter Region | counties - Alger Baraga Gogebic Huron Iron Keweenaw Luce Mecosta Menominee Presque Isle Schoolcraft Household size | Standard ($) 11 323 2 433 3 539 4 667 TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014

Michigan

Medicaid Eligibility

786 Additional incremental amount @ Yes (No 943 Increment amount $ |99 1,043 Name of region Description Shelter Region 2 Shelter Region 2 counties - Arenac Chippewa Delta Houghton Tosco Lake Manistee Oceana Ontonagon Osceola Oscoda Household size | Standard ($) Additional incremental amount 5 — @ Yes C No {1 324 F i Increment amount $ |99 | 2 439 Da ae a 3 550 = 4 678 ar5 798 R 6 955 + 7 1,055

TN No: Ml-13-0100-MM1 Michigan

Approval Date: 2/3/2014

Effective Date: January 1, 2014

Medicaid Eligibility

Description

Shelter Region 3 counties - Alcona Benzie ‘Cheboygan Crawford Dickinson Gladwin Hillsdale Jackson Kalkaska Mackinac Mason Missaukee Montcalm Muskegon Newaygo Ogemaw Sanilac Wexford

of

Name of region Shelter Region 3 Household size | Standard ($) Ea 331 ; |2 451 '¥

wT y13 564

4 692 |S 812 | i 6 970 i 7 1,070 :

Additional incremental amount @ Yes

C No

Increment amount $ |100

TN No: MI-13-0100-MM1 Michigan

Approval Date: 2/3/2014

Effective Date: January 1, 2014

Medicaid Eligibility

Name of region

Description

Shelter Region 4

Shelter Region 4 counties - Allegan Alpena Antrim Berrien Branch Calhoun

Cass Charlevoix Clare

Emmet Gratiot

Tonia

Isabella Marquette Montmorency Roscommon St. Joseph Shiawassee Tuscola

Wayne

Household size | Standard ($) f 2 473 3 587 4 718 ; 5 840 "16 999 7 1,101

Additional incremental amount @ Yes (© No

Increment amount $ .|102

TN No: MI-13-0100-MM1 Michigan

Approval Date: 2/3/2014

Effective Date: January 1, 2014

Medicaid Eligibility

Name of region

Description

Shelter Region 5

Shelter Region 5 counties - Barry

Bay

Clinton

Eaton

Grand Traverse Kalamazoo Kent

(Lapeer Leelanau Lenawee Midland Otsego

Ottawa Saginaw

Van Buren

Additional incremental amount

Household size | Standard ($) @ Yes (© No | 367 E Increment amount $ |103 " 2 489 3 604 ee) 4 734 oaes 15 856 1,016 1,118 Name of region Description Shelter Region 6 Genesee Ingham Livingston Macomb Monroe Oakland St. Clair Washtenaw Household size | Standard ($)

TN No: MI-13-0100-MM1

Approval Date: 2/3/2014

Effective Date: January 1, 2014

381

504

618

748

871

1,030

1,132

Additional incremental amount @ Yes

Increment amount $ |103

C No

C Yes

The dollar amounts increase automatically each year

@ No

The standard is

as follows:

C Statewide standard @ Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

TN No: MI-13-0100-MM1

Michigan

Approval Date: 2/3/2014

Effective Date: January 1, 2014

Medicaid Eligibility

Name of region

Description

Shelter Region 1

Shelter Region 1 counties - Alger Baraga Gogebic Huron

Iron ‘Keweenaw Luce Mecosta Menominee Presque Isle Schoolcraft

Additional incremental amount

Household size | Standard ($) a @ Yes (© No 255 \ Increment amount $ |76 341 424 528 . 624 757 833 Name of region Description Shelter Region 2 Shelter Region 2 counties - Arenac Chippewa Delta Houghton Iosco Lake (Manistee Oceana Ontonagon Osceola Oscoda Household size | Standard ($)

TN No: MI-13-0100-MM1 Michigan

Approval Date: 2/3/2014

Effective Date: January 1, 2014

Medicaid Eligibility

255 Additional incremental amount @ Yes C No

346 Increment amount $ |76

434

538

634

767

843

Name of region Description Shelter Region 3 Shelter Region 3 counties - Alcona Benzie Cheboygan (Crawford Dickinson Gladwin Hillsdale Jackson Kalkaska Mackinac Mason Missaukee Montcalm Muskegon Newaygo Ogemaw Sanilac ‘Wexford Household size | Standard ($)

260

356

444

548

TN No: MI-13-0100-MM1 Michigan

Approval Date: 2/3/2014

Effective Date: January 1, 2014

Medicaid Eligibility

644

777

853

Additional incremental amount @ Yes (C No

Increment amount $ |76

Name of region

Description

Shelter Region 4

Household size

Standard ($)

276

371

459

563

659

792

nN

868

SEA

tee Bes

a

Shelter Region 4 counties - Allegan Alpena Antrim Berrien Branch Calhoun

Cass Charlevoix Clare

Emmet Gratiot

Tonia

Isabella Marquette Montmorency Roscommon St. Joseph Shiawassee Tuscola

Wayne

Additional incremental amount @ Yes (No

Increment amount $ |76

TN No: MI-13-0100-MM1 Michigan

Approval Date: 2/3/2014

Effective Date:

January 1, 2014

Medicaid Eligibility

Name of region Description

Shelter Region 5 Shelter Region 5 counties - Barry

Bay

Clinton

Eaton

Grand Traverse Kalamazoo Kent

Lapeer Leelanau [Lenawee Midland Otsego

Ottawa Saginaw

/Van Buren

Household size | Standard ($) Additional incremental amount @ Yes CNo

290 i a Increment amount $ |76

386

474

578

Ei 674 i,

807

883

Name of region Description

Shelter Region 6 Genesee Ingham Livingston Macomb Monroe Oakland St. Clair Washtenaw

Michigan MM Approval Date: 2/3/2014 Effective Date: January 1, 2014 n

Medicaid Eligibility

Household size | Standard ($) Additional incremental amount @ Yes (© No 1 305 Increment amount $ |76 2 401 3 489 el 4 593 I 5 689 6 822 17 898 D

The dollar amounts increase automatically each year C Yes @ No

The standard is as follows:

C Statewide standard @ Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

TN No: MI-13-0100-MM1

A . Michigan pproval Date: 2/3/2014

Effective Date: January 1, 2014

Medicaid Eligibility

Name of region

Description

Shelter Region 1

Shelter Region 1 counties - Alger |Baraga Gogebic Huron

Iron Keweenaw [Luce Mecosta Menominee Presque Isle

Schoolcraft

Household size

Standard ($)

323

433

539

667

786

943

1,043

i s i

Name of region

Additional incremental amount @ Yes (No

Increment amount $ |99

Description

Shelter Region 2

Shelter Region 2 counties - Arenac Chippewa Delta Houghton Tosco Lake Manistee Oceana Ontonagon Osceola Oscoda

Household size

Standard ($)

TN No: Mi-13-0100-MM1 Michigan

Approval Date: 2/3/2014

Effective Date: January 1, 2014

Medicaid Eligibility

Additional incremental amount

324 @ Yes © No

439 Increment amount $ |99

550

678

798

955

1,055

Name of region Description Shelter Region 3 Shelter Region 3 counties - Alcona Benzie Cheboygan Crawford Dickinson Gladwin Hillsdale Jackson Kalkaska Mackinac Mason Missaukee Montcalm Muskegon Newaygo Ogemaw Sanilac Wexford Household size | Standard ($) 331 451 3 564 } 4 692

TN No: MI-13-0100-MM1 Michigan

Approval Date: 2/3/2014

Effective Date: January 1, 2014

Medicaid Eligibility

812

970

1,070

Additional incremental amount @ Yes (No

Increment amount $ |100

Name of region

Description

Shelter Region 4

Shelter Region 4 counties - Allegan Alpena Antrim Berrien Branch Calhoun

Cass Charlevoix Clare

Emmet Gratiot

Ionia

Isabella Marquette (Montmorency Roscommon.

‘|St: Joseph

Shiawassee Tuscola

Wayne

Household size | Standard ($)

352

473

587

718

840

999

1,101

Additional incremental amount @ Yes (No

Increment amount $ |102

TN No: MI-13-0100-MM1 Michigan

Approval Date: 2/3/2014

Effective Date: January 1, 2014

Medicaid Eligibility

Name of region Description

Shelter Region 5 Shelter Region 5 counties - Barry

Bay

Clinton

Eaton

Grand Traverse Kalamazoo Kent

[Lapeer (Leelanau [Lenawee Midland Otsego

Ottawa Saginaw

Van Buren

Household size | Standard ($) Additional incremental amount @ Yes (© No

367

Increment amount $ }103

2 489 x

3 604

14 734

*

|5 ; 856

|6 1,016

1,118

Name of region Description

Shelter Region 6 Genesee Ingham Livingston Macomb Monroe Oakland St. Clair Washtenaw

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 Michigan

Medicaid Eligibility

@ Yes (CNo

381 Increment amount $

504

618

748

871

1,030

1,132

Household size | Standard ($) Additional incremental amount

103

The dollar amounts increase automatically each year C Yes (@ No

The standard is as follows: * @ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

Household size | Standard ($) C Yes (C No

Additional incremental amount

Increment amount $

The dollar amounts increase automatically each year C Yes @ No

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014

Michigan

Effective Date: January 1, 2014

The standard is as follows: @ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

Additional incremental amount

Household size | Standard ($) C Yes C No

Increment amount $

The dollar amounts increase automatically each year C Yes @ No

The standard is as follows: @ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

Additional incremental amount

Household size | Standard ($) C Yes CNo

Increment amount $

The dollar amounts increase automatically each year C Yes (@ No

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 Michigan

Medicaid Eligibility

(CENTRE ROR ACAD Dh MEDICARE BEVICN

The standard is as follows: @ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

Additional incremental amount

Household size | Standard ($) C Yes CNo

Increment amount $

The dollar amounts increase automatically each year C Yes @ No

The standard is as follows: @ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

Additional incremental amount

Household size | Standard ($) C Yes CNo

Increment amount $

The dollar amounts increase automatically each year

C Yes @ No

PRA Disclosure Statement

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 Michigan

Medicaid Eligibility

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

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 Michigan

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expirati 0/3 4

42. CFR 435.110 1902(a)(10)(A)(D) 1931(b) and (d)

wi Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state.

The state attests that it operates this eligibility group in accordance with the following provisions:

[Mi] Individuals qualifying under this eligibility group must meet the following criteria:

im Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included.

The state elects the following options:

This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old,

provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training.

Options relating to the definition of caretaker relative (select any that apply): ; Pea aaee oO The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, do ce even after the partnership is terminated. ~ .

Definition of domestic partner:

The definition of caretaker relative includes other relatives of the child based on blood (including those of ' half-blood), adoption or marriage.

siblings, step-siblings,step-parents, aunts, uncles, niece, nephew,grandparent, Description of other (including great,great-great, etc.), first cousin, first cousin once removed, any relatives: aunt, uncle, niece, nephew prefixed by grand, great, or great-great, brother-in- law, sister-in-law. Any spouse of the above recognized by Michigan law.

oO The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care.

Options relating to the definition of dependent child (select the one that applies):

The state elects to eliminate the requirement that a dependent child must be deprived of parental support or

@ care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent.

TN No: MI-13-0100-MM1

Approval Date: 2/3/2014 Michigan

Effective Date: January 1, 2014

Medicaid Eligibility

The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies):

[M] Have household income at or below the standard established by the state.

im MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

[®] Income standard used for this group [®| Minimum income standard

The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in $14 AFDC Income Standards.

The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard.

[] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group.

The state's maximum income standard for this eligibility group is:

@ The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Cc The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 C demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 C demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 Michigan

Medicaid Eligibility

@ A percentage of the federal poverty level: 54 %

Cc The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in $14 AFDC Income Standards.

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage C increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in $14 AFDC Income Standards.

Cc The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. :

C Other dollar amount

[] Income standard chosen: Indicate the state's income standard used for this eligibility group: C The minimum income standard (© The maximum income standard

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage C increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards.

C Another income standard in-between the minimum and maximum standards allowed [M] There is no resource test for this eligibility group. [mM] Presumptive Eligibility

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

C Yes @No

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

i ne: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 ichigan

TN No: MI-13-0100-MM1 Michigan

Medicaid Eligibility

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

42 CFR 435.116 1902(a)(10)(A)()(I) and (IV) 1902(a)(10)(A)(ii)(1), (IV) and (IX) 1931(b) and (d)

1920

[mM] Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. The state attests that it operates this eligibility group in accordance with the following provisions: {li Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other

Caretaker Relatives at 42 CFR 435.110.

@ Yes ( No

im MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state.

[m] Income standard used for this group

{@] Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.)

The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so.

@ Yes (No

Enter the amount of the minimum income standard (no higher than 185% FPL):|185 % FPL

[m] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant [Z] women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group.

The state's maximum income standard for this eligibility group is:

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income

families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(TV) (mandatory poverty level-

related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) e (A)ii)C) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(TV)

(institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Approval Date: 2/3/2014 Effective Date: January 1, 2014

Medicaid Eligibility

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(EX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(D (pregnant women who meet AFDC financial eligibility criteria) and 1902(a){10)(A)(ii)'V) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C 185% FPL

The amount of the maximum income standard is:|195 % FPL

[ll] Income standard chosen Indicate the state's income standard used for this eligibility group: C The minimum income standard @ The maximum income standard C Another income standard in-between the minimum and maximum standards allowed. [i There is no resource test for this eligibility group. [ll Benefits for individuals in this eligibility group consist of the following: @ All pregnant women eligible under this group receive full Medicaid coverage under this state plan.

Pregnant wamen whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services.

[lM] Presumptive Eligibility

The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity.

@ Yes (© No [i] The presumptive period begins on the date the determination is made.

[| The end date of the presumptive period is the earlier of:

The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

[lM] There may be no more than one period of presumptive eligibility per pregnancy.

A written application must be signed by the applicant or representative.

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014

Michigan

Medicaid Eligibility

@ Yes ( No C The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included.

[Ml The presumptive eligibility determination is based on the following factors: [BN The woman must be pregnant [| Household income must not exceed the applicable income standard at 42 CFR 435.116. State residency Citizenship, status as a national, or satisfactory immigration status

The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group.

Cy

A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group:

Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan

o Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act

Oo Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental ([] Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

oO Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP)

Oo Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

(71 Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs (1 Is a state or Tribal child support enforcement agency under title IV-D of the Act

oO Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

oO Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act

TN we MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 Michigan .

Medicaid Eligibility

Is an organization that determines eligibility for any assistance or benefits provided under any program

oO of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization

[] Other entity the agency determines is capable of making presumptive eligibility determinations:

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

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

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 Michigan

TN No: MI-13-0100-MM1 Michigan

Medicaid Eligibility

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

42 CFR 435.118 1902(a)(10)(A)(i)(IIN,.(IV), (V1) and (VID) 1902(a)(10)(A)(ii)(IV) and (IX)

1931(b) and (d)

i Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group.

The state attests that it operates this eligibility group in accordance with the following provisions:

[M Children qualifying under this eligibility group must meet the following criteria: [@) Are under age 19

[M] Have household income at or below the standard established by the state.

ry MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

[lM] Income standard used for infants under age one

[= Minimum income standard

The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so.

@ Yes (© No

Enter the amount of the minimum income standard (no higher than 185% FPL):|185 % FPL

{™] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for infants

under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one.

The state's maximum income standard for this age group is:

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A){i)(III) (qualified children), 1902(a)(10)(A)(i)(1V) (mandatory poverty level-related

@ infants), 1902(a)(10)(A)(ii)(CX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

Approval Date: 2/3/2014 Effective Date: January 1, 2014

Medicaid Eligibility

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for any population of infants under age one under a Medicaid 1115

c demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. C 185% FPL Enter the amount of the maximum income standard: |195 % FPL

[mM] Income standard chosen

The state's income standard used for infants under age one is:

@

The maximum income standard

Ifnot chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IL) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II]) (qualified children), 1902(a)(10) (A)(i)(V) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. .

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010.

[m] Income standard for children age one through age five, inclusive

[®) Minimum income standard

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014

Michigan

Medicaid Eligibility

The minimum income standard used for this age group is 133% FPL. [&] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five.

The state's maximum income standard for children age one through five is:

The state's highest effective income level for coverage of children age one through five under sections 1931 (low-

@ income families), 1902(a)(10)(A)(i)(II) (qualified children), 1902(a)(10)(A)(i)( VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's highest effective income level for coverage of children age one through five under sections 1931 (low-

Cc income families), 1902(a)(10)(A)(i)(II) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

: -C The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration:as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Enter the amount of the maximum income standard: |160 % FPL

[M] Income standard chosen The state's income standard used for children age one through five is: (@ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children),

C 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IIT) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014

Effective Date: January 1, 2014 Michigan

COTE. HCA RRETREUD KERIO

Medicaid Eligibility

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL.

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010.

[Ml] Income standard for children age six through age eighteen, inclusive

ml

i

cy

Minimum income standard The minimum income standard used for this age group is 133% FPL.

Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen.

The state's maximum income standard for children age six through eighteen is:

The state's highest effective income level for coverage of children age six through eighteen under sections 1931

@ (low-income families), 1902(a)(10)(A)(i)(II) (qualified children), 1902(a)(10)(A)(i)(VID) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 Cc (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty

level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalize children), in effect

under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C 133% FPL

Enter the amount of the maximum income standard: |160 % FPL

Income standard chosen

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014

Michigan

Medicaid Eligibility

The state's income standard used for children age six through eighteen is:

(@ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL.

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010.

[@] There is no resource test for this eligibility group.

[M] Presumptive Eligibility

The state covers children when determined presumptively eligible by a qualified entity.

@ Yes (No

1902(a\(47) 1920A

42 CFR 435.1101 42 CFR 435.1102

im The state provides Medicaid coverage to children when determined presumptively eligible by a qualified entity under the following provisions:

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014

Michigan

cms Medicaid Eligibility

CONTE TOR NETCARE 8 SANT ANE ROUSE

If the state has elected to cover Optional Targeted Low-Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the higher of the standard used for Optional Targeted Low-Income Children or the standard used for Infants and Children under 19 (42 CFR 435.118), for that child’s age.

If the state has not elected to cover Optional Targeted Low Income Children (42 CFR 435.229), the income standard for presumptive eligibility is the standard used under the Infants and Children under Age 19 eligibility group (42 CFR 435.118), for that child’s age.

[Mf Children under the following age may be determined presumptively eligible:

Under age |19

[| The presumptive period begins on the date the determination is made.

[| The end date of the presumptive period is the earlier of:

The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by

the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

[&] Periods of presumptive eligibility are limited as follows: C No more than one period within a calendar year. C No more than one period within two calendar years.

No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

(Other reasonable limitation: -

The state requires that a written application be signed by the applicant, parent or representative, as appropriate. @ Yes (No

C The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included.

[B) The presumptive eligibility determination is based on the following factors:

[Mi] Household income must not exceed the applicable income standard described above, for the child's age.

State residency

Citizenship, status as a national, or satisfactory immigration status

rl The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group.

TN No: MI-13-0100-MM1

Approval Date: 2/3/2014 Effective Date: January 1, 2014

Medicaid Eligibility

' A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group:

Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan

oO Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act

oO Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental (1 Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

o Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP)

oO Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

[F Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs {71 Isa state or Tribal child support enforcement agency under title 1V-D of the Act

oO Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

o Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act

Is an organization that determines eligibility for any assistance or benefits provided under any program

oO of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an —' Urban Indian Organization

(J Other entity the agency determines is capable of making presumptive eligibility determinations:

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

PRA Disclosure Statement

TN No: MI-13-0100-MM1

Approval Date: 2/3/2014 Michigan

Effective Date: January 1, 2014

Medicaid Eligibility

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

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 Michigan

Medicaid Eligibility

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

1902(a)(10)(A)(i)(VIID), 42 CFR 435.119

The state covers the Adult Group as described at 42 CFR 435.119. C Yes @ No

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

Michigw ne tooMM Approval Date: 2/3/2014 Effective Date: January 1, 2014

Medicaid Eligibility

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

42 CFR 435.150 1902(a)(10)(A)(i)(IX)

im Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care.

The state attests that it operates this eligibility group under the following provisions:

[Ml] Individuals qualifying under this eligibility group must meet the following criteria: [Ml] Are under age 26. im Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group.

Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state

{mj plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program.

The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system.

@Yes (No

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

C Yes (@No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN No: MI-13-0100-MM1

Approval Date: 2/3/2014 Michigan

Effective Date: January 1, 2014

Medicaid Eligibility

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

1902(a)(10)(A)(ii)(XX) 1902(hh) 42 CFR 435.218

Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218.

C Yes @ No

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

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 Michigan

Medicaid Eligibility

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

42 CFR 435.220 1902(a)(10)(A)(ii)(D)

Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220.

C Yes @ No

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

TN No: MI-13-0100-MM1

A . Michigan Pproval Date: 2/3/2014

Effective Date: January 1, 2014

ccms Medicaid Eligibility

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

42 CFR 435.222 1902(a)(10)(A)(ii)(1) 1902(a)(10)(A)(ii)TV)

[Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222.

C Yes @ No

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

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014

Michigan Effective Date: January 1, 2014

Medicaid Eligibility

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

42 CFR 435.227 1902(a)(10)(A)(ii) (VID)

Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227.

@ Yes (C No The state attests that it operates this eligibility group in accordance with the following provisions:

[@] Individuals qualifying under this eligibility group must meet the following criteria:

Ty The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care;

[mM Are under the following age (see the Guidance for restrictions on the selection of an age): @ Under age 21 C Under age 20 C Under age 19 C Under age 18

im MAGI-based income methodologies are used in calculating household income. Please refer as necessary to $10 MAGI- Based Income Methodologies, completed by the state.

The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes (No

The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. @ Yes (No

im Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement.

The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes (CNo [M] Income standard used for this eligibility group

[®] Minimum income standard

The minimum income standard for this eligibility group is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in $14 AFDC Income Standards.

[] Maximum income standard

TN No: MI-13-0100-MM1

Approval Date: 2/3/2014 Michigan

Effective Date: January 1, 2014

Medicaid Eligibility

No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes (No

im No income test was used (all income was disregarded) for this eligibility group under (check all that apply):

The Medicaid state plan as of March 23, 2010.

The Medicaid state plan as of December 31, 2013.

(1 A Medicaid 1115 Demonstration as of March 23, 2010. oO A Medicaid 1115 Demonstration as of December 31, 2013.

The state's maximum standard for this eligibility group is no income test (all income is disregarded).

[lM] Income standard chosen

Individuals qualify under this eligibility group under the following income standard, which must be higher than the minimum for this child's age:

This eligibility group does not use an income test (all income is disregarded).

[mM] There is no resource test for this eligibility group.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN No: MI-13-0100-MM1 Michigan

Approval Date: 2/3/2014 Effective Date: January 1, 2014

Medicaid Eligibility

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

1902(a)(10)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B)

Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229.

C Yes @ No

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

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014

Michigan Effective Date: January 1, 2014

cCcms Medicaid Eligibility

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

1902(a)(10)(A)(ii)(XID) 1902(z)

Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services.

C Yes @ No

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

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 Michigan

Medicaid Eligibility

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

42, CFR 435.226 1902(a)(10)(A)(i)(XVID)

Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age

21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226.

@ Yes (© No The state attests that it operates this eligibility group in accordance with the following provisions: [lM] Individuals qualifying under this eligibility group must meet the following criteria:

[lM] Are under the following age @ Under age 21 C Under age 20 C Under age 19

[mM] Were in foster care under the responsibility of a state on their 18th birthday.

[M] Are not eligible and enrolled for mandatory coverage under the Medicaid state plan.

[m] Have household income at or below a standard established by the state.

im MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013.

@ Yes (No

The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. @ Yes (CC No

The state covers children under this eligibility group, as follows (selection may not be more restrictive than the rh coverage in the Medicaid state plan as of March 23, 2010 until October 1, 2019, nor more liberal than the most

liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013):

@ All children under the age selected C A reasonable classification of children under the age selected:

{| Income standard used for this eligibility group

[®] Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect

as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in $14 AFDC Income Standards.

TN No: MI-13-0100-MM1

Approval Date: 2/3/2014 Michigan

Effective Date: January 1, 2014

Medicaid Eligibility

[=] Maximum income standard

No ineome test was used (all income was disregarded) for this eligibility group either in the

Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes (© No

im No income test was used (all income was disregarded) for this eligibility group under (check all that apply):

The Medicaid state plan as of March 23, 2010.

The Medicaid state plan as of December 31, 2013.

(11 A Medicaid 1115 demonstration as of March 23, 2010.

{[] A Medicaid 1115 demonstration as of December 31, 2013.

The state's maximum standard for this eligibility group is no income test (all income is disregarded). [M] Income standard chosen

Individuals qualify under this eligibility group under the following income standard:

This eligibility group does not use an income test (all income is disregarded).

[B] There is no resource test for this eligibility group.

. : PRA Disclosure Statement ;

o According to the Paperwork Reduction Act of 1995; no:persons aré-required to fespond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 Michigan

Medicaid Eligibility

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

q

1902(a)(10)(A)(ii)(XXD) 42 CFR 435.214

Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214.

C Yes @ No

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

TN No: MI-13-0100-MM1 Approval Date: 2/3/2014 Effective Date: January 1, 2014 Michigan ‘

Table of Contents State/Territory Name: MI State Plan Amendment (SPA) #: 13-0120-MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

May 9, 2014

Stephen Fitton, Medicaid Director Medical Services Administration Federal Liaison Unit Michigan Department of Community Health 400 South Pine Lansing, Michigan 48933

ATTN: Loni Hackney

Dear Mr. Fitton:

Enclosed for your records is an approved copy of the following State Plan Amendment:

 Transmittal: #13-0120-MM7 Presumptive Eligibility by Hospitals  Effective: January 1, 2014

If you have any questions, please contact Leslie Campbell at (312) 353-1557 or Leslie.Campbell@cms.hhs.gov.

Sincerely,

/s/

Verlon Johnson

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Michigan

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-13-0120= My 71.

Proposed Effective Date ; OUor2014 tam dave)

Federal Statute/Regulation Citation 42 CFR 435.1110

Federal Budget Impact Federal Fiscal Year Amount

First Year 2014

Second Year 2015 —

Subject of Amendment This State Plan page specifies options for presumptive eligibility conducted by hospitals.

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

Comments of Governor's office received Describe:

No reply received within 45 days of submittal © Other, as specified

Describe:

Stephen Fitton, Director

Medical Services Administration

Signature of State Agency Official

Submitted By: Loni Hackney

Last Revision Date: May 1, 2014

Submit Date: Nov 12, 2013 DATE RECEIVED: November 12, 2013 DATE APPROVED: May 9, 2014

PLAN APPROVED — ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL: SIGNATURE OF REGIONAL OFFICIAL: January 1, 2014 /s/ TYPED NAME: TITLE: Verlon Johnson Associate Regional Administrator REMARKS:

TN No: 13-0120-MM7 Michigan Page 1 of 3 Approval Date: 5/9/14 Effective Date: 1/01/14

TN No: 13-0120-MM7 Michigan Page 2 of 3 Approval Date: 5/9/14 Effective Date: 1/01/14

TN No: 13-0120-MM7 Michigan Page 3 of 3 Approval Date: 5/9/14 Effective Date: 1/01/14

Table of Contents State/Territory Name: MI State Plan Amendment (SPA) #: 13-0130-MM4 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

May 2, 2014

Stephen Fitton, Medicaid Director Medical Services Administration Federal Liaison Unit Michigan Department of Community Health 400 South Pine Lansing, Michigan 48933

ATTN: Loni Hackney

Dear Mr. Fitton:

Enclosed for your records is an approved copy of the following State Plan Amendment:

 Transmittal: #13-0130 Single State Agency  Effective: January 1, 2014

If you have any questions, please contact Leslie Campbell at (312) 353-1557 or Leslie.Campbell@cms.hhs.gov.

Sincerely,

/s/

Verlon Johnson

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Michigan Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-Y¥-0000 where ST= the state abbreviation, Y¥ = the last two digits of

the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. MI-13-0130 - Mim if

Proposed Effective Date OUOUZO14 ._. Kan/ad/yyey) Federal Statute/Regulation Citation

42 CFR 431.10, 431.11, 431,12, 431.50

Federal Budget Impact Federal Fiscal Year Amount First Year .2014 $0.00 ; Second Year .2015_ $000 a ~~ Subject of Amendment

Establishes the Michigan Department of Community Health (MDCH) as the single state agency to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act.

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

Comments of Governor's office received Describe:

an

No reply received within 45 days of submittal ® Other, as specified

Describe: Stephen Fitton, Director Medical Services Administration Signature of State Agency Official Submitted By: Loni Hackney Last Revision Date: Apr 24, 2014 Submit Date: Oct 24, 2013 DATE RECEIVED: October 24, 2013 | DATE APPROVED: May 2, 2014 PLAN APPROVED — ONE COPY ATTACHED EFFECTIVE DATE OF APPROVED MATERIAL: SIGNATURE OF REGIONAL OFFICIAL: January 1, 2014 /s/ TYPED NAME: TITLE: Verlon Johnson Associate Regional Administrator REMARKS:

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

MI 13-0130 STATE:

Michigan

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

A1 – A3

COMPLETE PAGES SUPERSEDED:

Page 1

Section 1.1 (pages 2-6)

Section 1.2 (page 7)

Section 1.3 (page 8)

Section 1.4 (page 9)

Attachment 1.1-A (Attorney General certification)

Attachment 1.2-A (Organizational chart)

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

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

Attachment 1.2-D

A1-A2

Notwithstanding any other provisions of the Medicaid State Plan, the agencies designated in A1 and A2 will determine eligibility for coverage to the extent specified in A1 and A2.

TN No: MI-13-0130-MM4 Michigan Approval Date: 5/02/14 Effective Date: 1/01/14

TN No: MI-13-0130-MM4 Michigan Approval Date: 5/02/14 Effective Date: 1/01/14

TN No: MI-13-0130-MM4 Michigan Approval Date: 5/02/14 Effective Date: 1/01/14

TN No: MI-13-0130-MM4 Michigan Approval Date: 5/02/14 Effective Date: 1/01/14

TN No: MI-13-0130-MM4 Michigan Approval Date: 5/02/14 Effective Date: 1/01/14

TN No: MI-13-0130-MM4 Michigan Approval Date: 5/02/14 Effective Date: 1/01/14

TN No: MI-13-0130-MM4 Michigan Approval Date: 5/02/14 Effective Date: 1/01/14

TN No: MI-13-0130-MM4 Michigan Approval Date: 5/02/14 Effective Date: 1/01/14

Table of Contents

State/Territory Name: MI State Plan Amendment (SPA) #: 13-0140-MM2

This file contains the following documents in the order listed:

1) Approval Letter 2) Additional Companion letter 3) Summary Form (with 179-like data)

4) Approved SPA Pages 5) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services , ian Chicago Regional Office ? 233 N. Michigan

Suite 600 CENTERS FOR MEDICARE & MEDICAID SERVICES Chicago, Illinois 60601

February 10, 2014

Stephen Fitton, Medicaid Director

Medical Services Administration

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

RE: Michigan SPA 13-0140-MM2 Dear Mr. Fitton:

Enclosed is an approved copy of Michigan’s (MI) state plan amendment (SPA) MI 13-0140-MM2, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on November 12, 2013. SPA MI 13-0140-MM2 incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Michigan’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA MI 13-0140-MM2 includes approval of the state’s alternative single streamlined paper application. The State is also using an interim alternative single streamlined online application and by December 31, 2014 will implement a revised alternative single streamlined online application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following S94 state plan pages and attachments to be incorporated within a separate section at the end of Michigan’s approved state plan:

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

e Attachment | - Michigan Alternative Streamlined Application for Health Coverage & Help Paying Costs

e Attachment 2 — Statement of use with respect to the alternative single streamlined online application

e Attachment 3 — Statement of use with respect to the coordination of eligibility and enrollment

In addition, enclosed is a summary of state plan pages which are superseded by MI SPA 13-0140-MM2, which should also be incorporated into a separate section in the front of the state plan.

e Superseding Pages of State Plan Material, 13-0140-MM2

Page 2 Fitton

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan amendment. For technical assistance with your online application, please contact Dena Greenblum at (410) 786-8684 or ‘dena.greenblumv@cms.hhs.gov. If you have any questions concerning this SPA, please contact Leslie Campbell at 312 353-1557 or by email at Leslie.Campbell@cms.hhs.gov.

Sincerely,

/s/ Verlon Johnson Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosures

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

Chicago Regional Office

233 N. Michigan

Suite 600 CENTERS FOR MEDICARE & MEDICAID SERVICES

Chicago, Illinois 60601

February 10, 2014

Stephen Fitton, Medicaid Director

Medical Services Administration

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

RE: Michigan SPA 13-0140-MM2

Dear Mr. Fitton:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) 13-0140-MM2, which was submitted to CMS on November 12, 2013. Our review of this submission included a review of Michigan’s alternative single streamlined paper and

online applications developed by the state.

With respect to the renewal of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard, the state indicated that they are in the process of updating their systems to create pre-populated renewal forms, which will be used when an individual’s eligibility cannot be determined solely on the basis of information available to the agency. As

discussed, Michigan has scheduled this functionality to be put into production in December 2014.

Until December 31, 2014, the state is using an interim alternative single streamlined online application.

This interim online application will need to be revised to reflect the following changes.

Necessary changes:

Date by which changes will be completed:

e The state will ensure that only applicants who do not appear eligible for Medicaid and CHIP based on income attestation will be asked for information about access to employer-sponsored coverage, beyond what is needed for Medicaid and CHIP. Such applicants will be asked about the lowest-cost premium they are offered from an employer.

December 31, 2014

Page 2 Fitton

Please submit the revised alternative single streamlined online application to CMS for review no later than November 30, 2014 to ensure approval by December 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum@cms.hhs.gov or (410) 786-8684. If you have any questions about this

letter or need any additional information, please contact Leslie Campbell at (312) 353-1557 or Leslie.Campbell@cms.hhs.gov.

Sincerely,

{

Verlon Johnson Associate Regional Administrator Division of Medicaid and Children’s Health Operations

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Michigan

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-13-0140 ~aiM2

Proposed Effective Date 10/01/2013 (mm/dd/yyyy)

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

Federal Budget Impact Federal Fiscal Year First Year 2014 $0.00

Second Year 2015, $0.00

Amount

Subject of Amendment . Establishes the application the State will use for individuals who apply for coverage that may be eligible based on the MAGI standard.

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

Comments of Governor's office received Describes

No reply received within 45 days of submittal ‘®: Other, as specified

Describe:

Stephen Fitton, Director

Medical Services Administration

Signature of State Agency Official Submitted By: Loni Hackney Last Revision Date: Feb 5, 2014 Submit Date: Nov 12, 2013

DATE RECEIVED: DATE APPROVED: November 12, 2013 February 10, 2014 PLAN APPROVED — ONE COPY ATTACHED EFFECTIVE DATE OF APPROVED MATERIAL: SIGNATURE OF REGIONAL OFFICIAL: January 1, 2014 /s/ TYPED NAME: TITLE: Verlon Johnson Associate Regional Administrator REMARKS:

Medicaid Eligibility

(FACTORS PO RETIN A ARTCC NEL AEEMTONY

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

42 CFR 435, Subpart J and Subpart M

Eligibility Process

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

Application Processing

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

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

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

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

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

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

The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and BZ] approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary.

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

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

The agency also accepts applications by other electronic means:

@ Yes (C No

TN No: MI-13-0140-MM2 Approval Date: 2/10/14 Effective Date: 1/01/2014 Michigan

Medicaid Eligibility

ERATE RENAME 6 AREA ETC

Indicate the other electronic means below:

Name of Method Description

"| Local Office Kiosks Self-contained kiosks are located in the lobby of all local

o offices. In addition to the availability of the kiosks, each county has a ‘lobby management plan’ which includes a ‘lobby navigator.' The lobby navigators are available to assist applicants should they require assistance with the online application and/or require assistance related to the paper application.

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

Parents and Other Caretaker Relatives

Pregnant Women

Infants and Children under Age 19 Redetermination Processing

Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435,916:

[BJ Once every 12 months

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

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

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

Once every 12 months

[1 Once every 6 months

[C1 Other, more often than once every 12 months Coordination of Eligibility and Enrollment

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

PRA Disclosure Statement

TN No: MI-13-0140-MM2 Approval Date: 2/10/14 Effective Date: 1/01/2014 Michigan

Medicaid Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data

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

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

TN No: MI-13-0140-MM2

Approval Date: 2/10/14 Michigan

Effective Date: 1/01/2014

COORDINATION OF ELIGIBILITY AND ENROLLMENT

TRANSMITTAL NUMBER:

13-0140 MM2

STATE:

Michigan

Notwithstanding the final checked statement on page 2, the single state agency has not entered into an agreement with the Federally-facilitated Marketplace to date. The single state agency will make a good faith effort to enter into a memorandum of agreement with the Federally-facilitated Marketplace before May 1, 2014. At such time the agreement is signed, it will be incorporated by reference into this attachment

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: STATE:

13-0140-MM2 Michigan

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

Section 2, Page 10, section 2.1(a), TN #92-1, Effective $94 — Eligibility Process Date:10-01-91, Approved: 09-11-92

Section 2, Page | 1a, section 2.1(d), TN #91-30, Effective Date: 10-01-91, Approved: 07-06-92

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

CO Paper Application Online Application

TRANSMITTAL NUMBER: STATE:

MI-13-0140-MM2 Michigan

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

Table of Contents State/Territory Name: MI State Plan Amendment (SPA) #: 13-0150 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

February 10, 2014

Stephen Fitton, Medicaid Director Medical Services Administration Federal Liaison Unit Michigan Department of Community Health 400 South Pine Lansing, Michigan 48933

ATTN: Loni Hackney

Dear Mr. Fitton:

Enclosed for your records is an approved copy of the following State Plan Amendment:

 Transmittal: #13-0150 Citizenship and Non-Citizenship Eligibility  Effective: January 1, 2014

If you have any questions, please contact Leslie Campbell at (312) 353-1557 or Leslie.Campbell@cms.hhs.gov.

Sincerely,

/s/

Verlon Johnson

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Michigan

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-13-0150 -4m 6

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

Federal Statute/Regulation Citation 42 CFR 435.403

Federal Budget Impact Federal Fiscal Year

First Year 21 Second Year 2015

Subject of Amendment The State affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy related to immigrant eligibility.

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

Comments of Governor's office received Describe: _

No reply received within 45 days of submittal ‘© Other, as specified

Describe:

Stephen Fitton, Director

Medical Services Administration

Signature of State Agency Official

Submitted By: Loni Hackney

Last Revision Date: Jan 14, 2014

Submit Date: Nov 12, 2013 DATE RECEIVED: DATE APPROVED: November 12, 2013 February 10, 2014

PLAN APPROVED — ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL: SIGNATURE OF REGIONAL OFFICIAL: January 1, 2014 /s/ TYPED NAME: TITLE: Verlon Johnson Associate Regional Administrator REMARKS:

Medicaid Eligibility

OMB Control Number 0938-1148 MB Expirati 10, 4

1902(a)(46)(B)

8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4)

42 CFR 435.4

42 CFR 435.406

42 CFR 435.956

Citizenship and Non-Citizen Eligibility

The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status.

[Ml] The state provides Medicaid eligibility to otherwise eligible individuals: [lM] Who are citizens or nationals of the United States; and

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity [i] Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or

a satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

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

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process.

@ Yes (No

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

@ Yes (No The date benefits are furnished is: @ The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent.

C Other date, as described:

TN No: MI-13-0150-MM6 Approval Date: 2/10/14

Effecti : Michigan ctive Date: 1/01/2014

Medicaid Eligibility

The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613).

@ Yes (No

The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act.

C Yes (@No

ry An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan.

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

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

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

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

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

[&] Granted employment authorization under 8 CFR 274a.12(c); [m) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; [M] Under Deferred Enforced. Departure (DED) in accordance with a decision made by the President;

[m] Granted Deferred Action status; [| Granted an administrative stay of removal under 8 CFR 241; [m] Beneficiary of approved visa petition who has a pending application for adjustment of status;

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

[&] Has been granted employment authorization; or

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

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

TN No: MI-13-0150-MM6 Approval Date: 2/10/14

Nc Effective Date: 1/01/2014 Michigan

Medicaid Eligibility

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

[1 Other

The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following 4 individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration,

status and/or present an SSN: [IM] Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613;

ry Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b).

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

TN No: MI-13-0150-MM6 Approval Date: 2/10/14 Effective Date: 1/01/2014 Michigan

Table of Contents State/Territory Name: MI State Plan Amendment (SPA) #: 13-0160-MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

February 10, 2014

Stephen Fitton, Medicaid Director Medical Services Administration Federal Liaison Unit Michigan Department of Community Health 400 South Pine Lansing, Michigan 48933

ATTN: Loni Hackney

Dear Mr. Fitton:

Enclosed for your records is an approved copy of the following State Plan Amendment:

 Transmittal: #13-0160-MM5 State Residency  Effective: January 1, 2014

If you have any questions, please contact Leslie Campbell at (312) 353-1557 or Leslie.Campbell@cms.hhs.gov.

Sincerely,

/s/

Verlon Johnson

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Michigan

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-13-0160 --1/445

Proposed Effective Date 01/01/2014 (mm/add/yyyy)

Federal Statute/Regulation Citation _

42 CFR 435.403 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 - $ 000 © 7 Second Year 2 $ 0.00 a

Subject of Amendment This SPA affirms the State's residency regulations. In addition, it addresses interstate agreements and temporary absence from the state.

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

Comments of Governor's office received Descri

No reply received within 45 days of submittal ‘ Other, as specified Describe:

Stephen Fitton, Director Medical Services Administration

Signature of State Agency Official

Submitted By: Loni Hackney

Last Revision Date: Jan 14, 2014

Submit Date: Nov 12, 2013 DATE RECEIVED: DATE APPROVED: November 12, 2013 February 10, 2014

PLAN APPROVED — ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL: SIGNATURE OF REGIONAL OFFICIAL: January 1, 2014 /s/ TYPED NAME: TITLE: Verlon Johnson Associate Regional Administrator REMARKS:

Medicaid Eligibility

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

42 CFR 435.403

State Residency

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

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

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

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

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

[m] Non-institutionalized individuals under 21 not described above and non IV-E beneficiary children:

[i] Residing in the state, with or without a fixed address, or

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

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

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

Regardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual's a 1 placement, or

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

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

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

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

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

TN No: MI-13-0160-MMS Approval Date: 2/10/14 Effective Date: 1/01/2014 Michigan

Medicaid Eligibility

[| Otherwise meet the requirements of 42 CFR 435.403.

TN No: MI-13-0160-MM5 Approval Date: 2/10/14 Effective Date: 1/01/2014 Michigan

Medicaid Eligibility

Meet the criteria specified in an interstate agreement. @ Yes ( No

[Ml] The state has interstate agreements with the following selected states:

[Xx] Alabama Illinois [Xx] Montana Rhode Island ><] Alaska [x] Indiana | Nebraska | South Carolina [Xx] Arizona [X] Iowa IX] Nevada [X] South Dakota [X] Arkansas [<] Kansas [X] New Hampshire KX] Tennessee [X] California [<] Kentucky [DX] New Jersey [X] Texas

[Xx] Colorado [X] Louisiana [X] New Mexico [X] Utah

[X} Connecticut [Xx] Maine C1 New York [X] Vermont

[X] Delaware [><] Maryland XX] North Carolina XX] Virginia

[X| District of Columbia ><] Massachusetts [><] North Dakota [><] Washington XX] Florida (1 Michigan EX] Ohio JX] West Virginia [<] Georgia [><] Minnesota |] Oklahoma >] Wisconsin [X] Hawaii XX] Mississippi [X] Oregon C1 Wyoming

EX] Idaho X] Missouri [><] Pennsylvania

The interstate agreement contains a procedure for providing Medicaid to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who (select all that apply):

Are IV-E eligible

[[] Are in the state only for the purpose of attending school

(7) Are out of the state only for the purpose of attending school

[2] Retain addresses in both states

[[] Other type of individual The state has a policy related to individuals in the state only to attend school. C Yes (@ No

[mM] Otherwise meet the criteria of resident, but who may be temporarily absent from the state.

The state has a definition of temporary absence, including treatment of individuals who attend school in another state.

@ Yes (C No

TN No: MI-13-0160-MMS5 Approval Date: 2/10/14 Effective Date: 1/01/2014 Michigan

SOMSERG EME METOCARY & ETIOCARE RERNOCRY

Medicaid Eligibility

Provide a description of the definition:

Self-attestation of Michigan residency by the individual. Residency continues for an individual who is temporarily absent from Michigan or intends to return to Michigan when the purpose of the absence has been accomplished. Example: Including but not limited to individuals who spend the winter months in a warmer climate and return to their home in the spring. They remain MI residents during the winter months

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN No: MI-13-0160-MM5 Approval Date: 2/10/14

Michigan Effective Date: 1/01/2014

Table of Contents State/Territory Name: MI State Plan Amendment (SPA) #: 14-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Department of Health & Human Services

Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

December 11, 2014

Stephen Fitton, Medicaid Director Medical Services Administration Federal Liaison Unit Michigan Department of Community Health 400 South Pine Lansing, Michigan 48933

ATTN: Loni Hackney

Dear Mr. Fitton:

Enclosed for your records is an approved copy of the following State Plan Amendment:

 Transmittal: #14-0008 Health Home  Effective: July 1, 2014

If you have any questions, please contact Leslie Campbell at (312) 353-1557 or Leslie.Campbell@cms.hhs.gov.

Sincerely,

/s/

Alan Freund

Acting Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

State/Territory name: Michigan Medicaid agency: Department of Community Health

Name: Loni Hackney

Title: Federal Liaison

Telephone number: (517) 335-5303

Email: Hackneyl@michigan.gov

Name: Stephen Fitton

Title: Medicaid Director

Telephone number: (517) 335-5303

Email: Fittons@michigan.gov

OMB Control Number: 0938-1148 Expiration date: 10/31/2014 Transmittal Number: MI-14-0008 Supersedes Transmittal Number: N/A Proposed Effective Date: Jul 1, 2014 Approval Date: Attachment 3.1-H Page Number: 1

Submission Summary 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-14-0008

Supersedes Transmittal Number: Please enter the Supersedes 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. N/A

The State elects to implement the Health Homes State Plan option under Section 1945 of the Social Security Act. Name of Health Homes Program: Chronic Care Management for Individuals with Serious and Persistent Mental Health Conditions State Information

Authorized Submitter and Key Contacts The authorized submitter contact for this submission package.

The primary contact for this submission package.

The secondary contact for this submission package.

Name: Lynda Zeller

Title: Deputy Director, Behavioral Health and Developmental Disabilities Admini Telephone number: (517) 335-0196

Email: ZellerL2@michigan.gov

Name: Elizabeth Knisely

Title: Directory, Bureau of Community Based Services

Telephone number: (517) 335-8401

Email: Kniselye@michigan.gov

The tertiary contact for this submission package.

Proposed Effective Date 07/01/2014 (mm/dd/yyyy)

Executive Summary Summary description including goals and objectives: In the 2014-15 Michigan Executive Budget the state committed to pilot Medicaid Health Homes in up to three regions for individuals with a serious and persistent mental health condition beginning July 1, 2014. Michigan will designate the community mental health service programs (CMHSPs) as Health Homes that will serve as the central point for directing patient- centered care among beneficiaries with a serious and persistent mental health condition and high rates of inpatient hospitalization or emergency department (ED) use. Individuals may also have a coexisting chronic medical condition (e.g., congestive heart failure congestive heart failure, insulin dependent diabetes, chronic obstructive pulmonary disorder, seizure disorder, etc.). CMHSP Health Homes are accountable for reducing avoidable health care costs (specifically preventing hospital admissions/readmissions and avoidable emergency room visits) and providing timely post-discharge follow-up. Health Homes are intended to improve beneficiary outcomes by addressing whole-person health care needs through provision of comprehensive, integrated behavioral health (mental health and substance use disorder), medical, care coordination and management services. Health Homes meet CMS' and Michigan's shared goals of improving beneficiary experience of care (including both care and experience), improving population health, and reducing per capita cost of health care spending.

Federal Budget Impact Federal Fiscal Year Amount First Year 2014

$ 899280.00 Second Year 2015

$ 3597122.00

Federal Statute/Regulation Citation Section 1945 of the Social Security Act

Governor's Office Review

No comment. Comments received. Describe:

No response within 45 days. Other. Describe: Stephen Fitton, Director Medical Services Administration Transmittal Number: MI-14-0008 Supersedes Transmittal Number: N/A Proposed Effective Date: Jul 1, 2014 Approval Date:

Date Received: June27, 2014 Date Approved: Plan Approved – One Copy Attached Effective Date of Approved Material: July 1, 2014 Signature of Regional Official: /s/ Typed Name: Alan Freund Title: Acting Associate Regional Administrator Remarks:

December 11, 2014

x

12/11/14

12/11/14

12/11/14

12/11/14

12/11/14

12/11/14

12/11/14

12/11/14

12/11/14

12/11/14

12/11/14

12/11/14

12/11/14

Attachment 4.19 H Page 15

{] Fee for Service ("7 Alternative Model of Payment (describe in Payment Methodology section) {2} Other

Description:

{_] Other Service Delivery System:

Describe if the providers in this other delivery system will be a designated provider or part of the team of health care rofessionals and how payment will be delivered to these providers:

:"} The State provides assurance that any contract requirements specified in this section will be included in any new or the next contract amendment submitted to CMS for review.

TN# 14-0008 Approval Date: Supersedes: New Effective Date: 7-1-14

12/11/14

12/11/14

12/11/14

12/11/14

Table of Contents

State/Territory Name: MI State Plan Amendment (SPA) #: 14-0170

This file contains the following documents in the order listed:

1) Approval Letter 2) Additional Companion letter 3) CMS 179 Form/Summary Form (with 179-like data)

4) Approved SPA Pages

Department of Health & Human Services Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

June 26, 2014

Stephen Fitton, Medicaid Director

Medical Services Administration

Federal Liaison Unit

Michigan Department of Community Health 400 South Pine

Lansing, Michigan 48933

ATTN: Loni Hackney

Dear Mr. Fitton:

Enclosed for your records is an approved copy of the following State Plan Amendment:

> Transmittal: #14-0170 Adult Group Coverage

> Effective: April 1, 2014

A companion letter will accompany this approval to address the state’s compliance on presumptive eligibilities requirements. If you have any questions, please contact Leslie Campbell at

(312) 353-1557 or Leslie.Campbell@cms.hhs.gov.

Sincerely,

/s/ Verlon Johnson

Associate Regional Administrator Division of Medicaid & Children’s Health Operations

Enclosures

Department of Health & Human Services Centers for Medicare & Medicaid Services Peye 233 North Michigan Avenue, Suite 600

Chicago, Illinois 60601-5519 CENTERS FOR MEDICARE & MEDICAID SERVICES

June 26, 2014

Stephen Fitton, Medicaid Director

Medical Services Administration

Federal Liaison Unit

Michigan Department of Community Health 400 South Pine

Lansing, Michigan 48933

ATTN: Loni Hackney Dear Mr. Fitton:

This letter is being sent as a companion to our approval of Michigan State Plan Amendment (SPA) 14-0170, which authorizes the state to provide Medicaid coverage to the adult group and to provide presumptive eligibility (PE) for this group. Our review of SPA 14-0170 included a review of the state’s training materials and on-line screens for PE and discussions with the state about how the state has implemented PE. Based on our review, the SPA has been approved. However, it was determined that state systems are not in compliance with one aspect of the federal Medicaid rules for PE.

Federal regulations at 42 CFR 435.1101 and the statute at section 1920 of the Social Security Act require that an individual’s PE period end on the date that Medicaid eligibility is determined, if the individual files a Medicaid application by the end of the month after the month that PE is determined. If the individual does not file a Medicaid application by the end of the month after the month that PE is determined, PE ends on that day. Federal financial participation (FFP) may not be claimed for services received on dates of service after an individual is no longer eligible. In our process of reviewing this SPA, Michigan informed us that, based on current systems functionality, it is not able to automatically end a PE period when a PE enrollee is denied Medicaid eligibility. The state continues the PE period until the end of that month, and continues to pay claims for services received during that time. We understand that state systems will need to be changed in order to come into compliance with federal rules governing the PE period and have discussed with the state the need to make these changes.

Please respond within 30 days from the date of this letter with a corrective action plan (CAP) that

describes the steps the state is taking to resolve the issue identified above. The CAP should include

the following information:

e Description of how and when the state’s systems will be corrected to allow for the PE period to be ended correctly so that FFP will not be claimed for dates of service beyond which the individual is eligible.

Page 2 Mr. Fitton

e Description of a manual workaround to be implemented in the interim (while awaiting systems changes) to assure that FFP will not be claimed for dates of service when an individual is no longer eligible. This workaround should be implemented as soon as possible to prevent inappropriate payments.

During the 30-day period, we are available to provide any technical assistance that you need. State plans that are not in compliance with Federal requirements at 42 CFR 430.10 are grounds for initiating a formal compliance process.

If you have any questions, please have a member of your staff contact Leslie Campbell at (312) 353-1557 or by email at Leslie.Campbell@cms.hhs.gov .

Sincerely,

/s/ Verlon Johnson Associate Regional Administrator Division of Medicaid and Children’s Health Operations

Cems Medicaid Eligibility

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

1902(a)(10)(A)(i)( VID) 42 CFR 435.119

The state covers the Adult Group as described at 42 CFR 435.119. @ Yes (CC No {™] Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. The state attests that it operates this eligibility group in accordance with the following provisions: [li] Individuals qualifying under this eligibility group must meet the following criteria:

[i] Have attained age 19 but not age 65.

{@ Are not pregnant. [Hf Are not entitled to or enrolled for Part A or B Medicare benefits.

ml Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B.

Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible. [i] Have household income at or below 133% FPL. Ty MAGI-based income methodologies are used in calculating household income. Please refer as necessary to $10 MAGI-Based Income Methodologies, completed by the state. [ There is no resource test for this eligibility group.

Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is [mi receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as

defined in 42 CFR 435.4. @ Under age 19, or C A higher age of children, if any, covered under 42 CFR 435.222 on March 23, 2010:

[H] Presumptive Eligibility

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR

435.118) eligibility groups when determined presumptively eligible.

@ Yes (C No

[Hi] The presumptive period begins on the date the determination is made.

TN No: 14-0170 Approved Date: 6-26-14 Effective Date: 4-1-14

Michigan

Medicaid Eligibility

Oo Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental

(J) Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

o Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP)

o Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

(1 Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs

(7 Is a state or Tribal child support enforcement agency under title IV-D of the Act

Oo Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

Oo Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act Is an organization that determines eligibility for any assistance or benefits provided under any program

o of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization

([) Other entity the agency determines is capable of making presumptive eligibility determinations:

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

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

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: 14-0170 Approved Date: 6-26-14 Effective Date: 4-1-14

Michigan

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name:

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-¥¥-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-14-0170 ~ 4417

Michigan

Proposed Effective Date

04/01/2014 “ (nn/atd/yyyy)

Federal Statute/Regulation Citation 42 CFR 435; 1902(a)(10A i) and (ii); 1905(a2)B); 1920; and 1931(b) and (d)

Federal Budget Impact Federal Fiscal Year Amount

First Year 2014

$ 766520086.00

Second Year 2015 $ 2660552984.00. ~

Subject of Amendment This amendment is submitted in order implement coverage of the adult group effective April 1, 2014. This SPA supersedes $32 previously submitted in TN No. 13-0100.

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

Comments of Governor's office received Describe:

No reply received within 45 days of submittal ’ Other, as specified

Describe:

Stephen Fitton, Director

Medical Services Administration

Signature of State Agency Official

Submitted By: Loni Hackney Last Revision Date: May 5, 2014 Submit Date: Apr 1, 2014

DATE RECEIVED: 4/1/14

| DATE APPROVED: 6/26/14

PLAN APPROVED ~— ONE COPY ATTACHED

EFFECTIVE DATE OF APPROVED MATERIAL: RRNA April 1, 2014 LC

SIGNATURE OF REGIONAL OFFICIAL: /s/

TYPED NAME: Verlon Johnson

TITLE: Associate Regional Administrator

REMARKS:

Table of Contents State/Territory Name: MI State Plan Amendment (SPA) #: 15-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Chicago Regional Office 233 N. Michigan Suite 600 Chicago, Illinois 60601

February 25, 2016

Chris Priest Medical Services Administration Michigan Department of Health and Human Services 400 South Pine Street, P.O. Box 30479 Lansing, Michigan 48909-7979

ATTN: Erin Black

Dear Mr. Priest:

Enclosed for your records is an approved copy of the following State Plan Amendment:

 Transmittal #: 15-0015: Medicaid Expansion Cost Sharing  Effective: January 1, 2016

If you have any questions, please contact Leslie Campbell at (312) 353-1557 or Leslie.Campbell@cms.hhs.gov.

Sincerely,

/s/

Ruth A. Hughes

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTHCARE FINANCING ADMINISTRATION OMB NO. 0938-0193 FORM HCFA-179(07-92) Instructions on Back TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: 1 5 - 0015 2. STATE: Michigan 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH FINANCING ADMINISTRATION DEPARTMENT OF HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE January 1, 2016 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2016 $0 b. FFY 2017 $0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 4.18-F, Pages 1,2,3,4 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): New Attachment 10. SUBJECT OF AMENDMENT: Establish a premium section due to transition from MIChild to Medicaid Expansion. 11. GOVERNOR'S REVIEW (Check One): GOVERNOR'S OFFICE REPORTED NO COMMENT COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL OTHER, AS SPECIFIED: Chris Priest, Director Medical Services Administration 12. SIGNATUE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Medical Services Administration Actuarial Division - Federal Liaison Capitol Commons Center - 7th Floor 400 South Pine Lansing, Michigan 48933 Attn: Erin Black 13. TYPED NAME: Chris Priest 14. TITLE: Director, Medical Services Administration 15. DATE SUBMITTED: December 16, 2015 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18 DATE APPROVED: PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPE NAME: 22. TITLE: 23. REMARKS: December 16, 2015

February 25, 2016 January 1, 2016

/s/ Ruth A. Hughes

Associate Regional Administrator

OMB Approved # 0938-0993 Revision: April 2006

Attachment 4.18-F

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN

TN No. 15-0015

Approval Date: _2/25/16_______ Effective Date: 1/01/2016

Supersedes

TN No. NEW

CMS-101090 (09/06)

It should be noted that States can select one or more options in imposing premiums.

A. For groups of individuals with family income at or below 100 percent of the FPL:

1. Premiums

a. _X_/ No premiums will be imposed for individuals with family income at or below 100 percent of the FPL.

__/ Other (specify the premium amounts by group and income level).

B. For groups of individuals with family income above 100 percent but below 150 percent of the FPL:

1. Premiums

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

OMB Approved # 0938-0993 Revision: April 2006

Attachment 4.18-F

Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN

TN No. 15-0015

Approval Date: _2/25/16_______ Effective Date: 1/01/2016

Supersedes

TN No. NEW

CMS-101090 (09/06)

C. For groups of individuals with family income above 150 percent of the FPL:

1. Premiums

a. __/ No premiums are imposed. b. X/ Premiums are imposed under section 1916A of the Act as follows (specify the premium amount by group and income level.

Group of Individuals Premium Method for Determining Family Income (including monthly or quarterly period)

Optional targeted low income children as described in 1902(a)(10)(A)(9ii)(XIV) and 42 CFR 435.229 who are under 19 years of age and whose income is between 160-212 per cent of the Federal Poverty Level. $10.00 per month per family Modified Adjusted Gross Income (MAGI) method is applied when determining eligibility for this Medicaid expansion group

Attach a schedule of the premium amounts for the various eligibility groups.

Not Applicable: The premium is set at $10.00 per month per family.

b. Limitation:  The total aggregate amount of premiums and cost sharing imposed for all individuals in the family may not exceed 5 percent of the family income of the family involved, as applied on a monthly or quarterly basis as specified by the State above.

OMB Approved # 0938-0993 Revision: April 2006

Attachment 4.18-F

Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN

TN No. 15-0015

Approval Date: _2/25/16_______ Effective Date: 1/01/2016

Supersedes

TN No. NEW

CMS-101090 (09/06)

c. No premiums shall be imposed for the following individuals:  Individuals under 18 years of age that are required to be provided medical assistance under section 1902(a)(10)(A)(i), and including individuals with respect to whom aid or assistance is made available under part B of title IV to children in foster care and individuals with respect to whom adoption or foster care assistance is made available under part E of such title, without regard to age;  Pregnant women;  Any terminally ill individual receiving hospice care, as defined in section 1905(o);  Any individual who is an inpatient in a hospital, nursing facility, intermediate care facility, or other medical institution, if such individual is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual’s income required for personal needs; and  Women who are receiving Medicaid by virtue of the application of sections 1902(a)(10)(A)(ii)(XVIII) and 1902(aa) of the Act.  An Indian who is eligible to receive or has received an item or service furnished by an Indian health care provider or through referral under contract health services is exempt from premiums.

d. Enforcement

1. __/ Prepayment required for the following groups of individuals who are applying for Medicaid:

2. X/ Eligibility terminated after failure to pay for 60 days for the following groups of individuals who are receiving Medicaid: Optional targeted low income children as described in 1902(a)(10)(A)(9ii)(XIV) and 42 CFR 435.229 who are under 19 years of age and whose income is between 160-212 per cent of the Federal Poverty Level.

3. __/ Payment will be waived on case-by-case basis for undue hardship.

D. Period of determining aggregate 5 percent cap

Specify the period for which the 5 percent maximum would be applied.

__ / Quarterly

__/ Monthly

OMB Approved # 0938-0993 Revision: April 2006

Attachment 4.18-F

Page 4

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State of MICHIGAN

TN No. 15-0015

Approval Date: _2/25/16_______ Effective Date: 1/01/2016

Supersedes

TN No. NEW

CMS-101090 (09/06)

NOTE: MIChild premiums may only be charged to families between 160% and 212% of the FPL and there are no co-payments. The only other eligibility group within this FPL range in the State is for pregnant women. The State does not charge premiums to pregnant women and pregnancy related services have no copays. Therefore, the State anticipates the only Medicaid cost sharing in a Medicaid expansion household would be the $10 per family per month premium, and is not tracking the 5% aggregate limit for Medicaid expansion households.

Table of Contents State/Territory Name: MI State Plan Amendment (SPA) #: 15-0100 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Medicaid State Plan Eligibility: Summary Page (CMS 179) 4"fl'm ;;;;a;.:;.:UUU:.::.n:.::u 'ftiMifil" '?ZTW'llNi!,. WWWWi'T..-Z.:.i'S&'li"i.'llW

i"t&?NZ6..YllZ ™.Yitfll"M.&.. State/Territory name: Michigan 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 ear, and 0000 = a four digit number with leading zeros. The dashes must also be entered. Ml-15-0100 Proposed Effective Date 1 ..... 0_11_0_11_20_ 1_6 ___ __.I (mm/ dd/yyyy) Federal Statute/Re ulation Citation 42 CFR 435; l 902(a)(l O)(A)(i) and (ii); l 905(u)(2)(B); Federal Budget Impact Federal Fiscal Year Amount First Year !2016 Second Year 12017 Subject of Amendment This amendment adds the optional eligibility group targeted low income children category due to the transition from MIChild to Medicaid Expansion. This is an eligibility group the state may elect to cover under its Medicaid program. Governor's Office Review O Governor's office reported no comment O Comments of Governor's office received Describe: O No reply received within 45 days of submittal @ Other, as specified Describe: Chris Priest, Director Medical Services Administration Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Erin Black Feb 29, 2016 Dec 16, 2015 Date Received: December 16, 2015 Date Approved: Plan Approved – One Copy Attached Effective Date of Approved Material: January 1, 2016 Signature of Regional Official: Typed Name: Title: Associate Regional Administrator Remarks: Ruth A. Hughes /s/ March 3, 2016

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Chicago Regional Office 233 N. Michigan Suite 600 Chicago, Illinois 60601

March 3, 2016

Chris Priest, Medicaid Director Medical Services Administration Federal Liaison Unit Michigan Department of Community Health 400 South Pine Lansing, Michigan 48933

ATTN: Erin Black

Dear Mr. Priest:

Enclosed for your records is an approved copy of the following State Plan Amendment:

 Transmittal #: 15-0100 – MIChild Transition  Effective: January 1, 2016

If you have any questions, please contact Leslie Campbell at (312) 353-1557 or Leslie.Campbell@cms.hhs.gov.

Sincerely,

/s/

Ruth A. Hughes

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

State Name:!Michigan JPi,iili Transmittal Number! MI - 15 - 0100 1902(a)(l O)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B) Medicaid Eligibility OMB Control Number: 0938-1148 Expiration date: 10/31/2014 Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. (e Yes (' No [ZI The state attests that it operates this eligibility group in accordance with the following provisions: x Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group. x MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SlO MAGI- 1111 Based Income Methodologies, completed by the state. The state covered this eligibility group in the state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013. (' Yes (e No x Individuals are covered under this eligibility group, as follows: (e All children under age 18 or 19 are covered: (e Under age 19 (' Under age 18 (' Reasonable classifications of children are covered. [ZI The income standard used for this eligibility group is higher than the lowest income standard chosen for children in the ./ age group selected above, under the mandatory Infants and Children under Age 19 eligibility group. The income standard used is: (' 200% FPL. (e A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) • of the Act, but by no more than 50 percentage points: y%FPL x There is no resource test for this eligibility group. x Presumptive Eligibility Presumptive eligibility for this group depends upon the selection of presumptive eligibility for the Infants and Children x under Age I 9 eligibility group. If presumptive eligibility is done for that group, it is done for this group under the same provisions. TN #: MI-15-0100-MM1 Michigan Approval Date: Effective Date: January 1, 2016 3/3/16

Medicaid Eligibility _ , PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s} or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20140415 TN #: MI-15-0100-MM1 Michigan Approval Date: Effective Date: January 1, 2016 3/3/16

Table of Contents State/Territory Name: MI State Plan Amendment (SPA) #: 15-1000 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Chicago Regional Office 233 N. Michigan Suite 600 Chicago, Illinois 60601 September 30, 2015 Kathy Stiffler, Acting Director Medical Services Administration Michigan Department of Health and Human Services 400 South Pine Street, P.O. Box 30479 Lansing, Michigan 48909-7979 ATTN: Erin Black Dear Ms. Stiffler: Enclosed for your records is an approved copy of the following State Plan Amendment: Transmittal #: 15-1000: Enrollment of Psychologist, Social Workers and Professional Counselors as Medicaid Providers in the Alternative Benefits Plan Effective: September 1, 2015 If you have any questions, please contact Leslie Campbell at (312) 353-1557 or Leslie.Campbell@cms.hhs.gov. Sincerely, /s/ Ruth A. Hughes Associate Regional Administrator Division of Medicaid & Children’s Health Operations Enclosures

Medicaid Alternative Benefit Plan: Summary Page (CMS 179) State/Territory name: Michigan Transmittal Number: Please enter the Transmittal Number (I'N) 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. Ml-15-1000 Propmno-pffective Date 09/01/2015 (mm/dd/yyyy) Federal Statute/Regyilation Citation ____ 42 C.F.R430.12(c) Federal Budget Impact Federal Fiscal Year First Year 2015 Second Year 2016 Subject of Amendment Amount $0.00 $0.00 This State Plan Amendment (SPA) is submitted in order to allow the enrollment of psychologists, social workers and professional counselors as Medicaid providers. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Kathleen Stiffler, Acting Director Medical Services Administration Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Erin Black Sep 21, 2015 Jul13,2015 DATE RECEIVED: July 13, 2015 DATE APPROVED: PLAN APPROVED – ONE COPY ATTACHED EFFECTIVE DATE OF APPROVED MATERIAL: September 1, 2015 SIGNATURE OF REGIONAL OFFICIAL: TYPED NAME: Ruth A. Hughes TITLE: Associate Regional Administrator REMARKS: September 30, 2015 /s/

Alternative Benefit Plan OMB Control Number: 0938-1148 The state/territory proposes a "Benchmark-Equivalent" benefit package.c Benefits Included in Alternative Benefit Plan Enter the specific name of the base benchmark plan selected: ! Priority Health HMO Enter the specific name of the section 1937 coverage option selected, if other than Secretary-Approved. Otherwise, enter "Secretary-Approved." Secretary-Approved For any Home and Community Based Services benefits as permitted in 1915(i) in ABP 5, the state assures that: 1. The service(s) are provided in settings that meet HCB setting requirements; 2. The services(s) meet the person-centered service planning requirements; 3. Individuals receiving these services meet the state-established needs-based criteria that are not related solely to age, disability, or diagnosis, and are less stringent than criteria for entry into institutions. Services can be accessed as needed, even if the individuals have needs that are below institutional level of care.

TN No: 15-1000 Michigan ABP5 Page 1 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Essential Health Benefit l: Ambulatory patient services Collapse All O Benefit Provided: 'Physician Services Authorization: I None Amount Limit: I see below Scope Limit:  Source: I !state Plan l 905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None Services must be related to a diagnosed mental or physical health condition calling for therapeutic management, an exam to diagnose a mental deficiency, or family planning. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Includes Primary Care and Specialist/Referral Physician Services; Other Practitioner Services (e.g. Nurse Practitioner, Physician Assistant). No payments for services of staff in residence (e.g. interns and residents) or for staff functioning in an administrative capacity. Physician services related to a diagnosed mental health condition in an inpatient setting are covered only when rendered by a psychiatrist or physician (MD or DO), or psychological testing by a licensed psychologist under the direction of a psychiatrist or physician (MD or DO). Laboratory services performed in the physician office are limited to those determined to be reasonable and appropriate for that site. Physician visits in a nursing home setting are limited to one visit per month; additional visits must be documented as medically nece§sary. Benefit Provided: !outpatient Hospital Services Authorization: I other Amount Limit: I None Scope Limit: Source: I !state Plan l 905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None 'Outpatient hospital services and supplies, including services performed by physicians and other health professionals; received on an outpatient basis. Certain services require prior authorization. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: !Benefit also includes ambulatory surgery center facility services. Benefit Provided: IHome Health Care Authorization: !Authorization required in excess of limitation Source: I I state Plan l 905(a) Provider Qualifications: I !Medicaid State Plan 11 · • R:erri<1\i ··1 ' '

I I 11 Remove I I I I I TN No: 15-1000 Michigan ABP5 Page 2 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Amount Limit: !Described Below Scope Limit: Duration Limit: I !Described Below Services described below are covered when provided to a beneficiary in his/her place of residence and ordered by a physcian as part of a comprehensive written plan of care. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Intermittent skilled services are covered, including nursing services, home health aide services, physical therapy, and occupational therapy. Home health care services are not covered for beneficiaries in a hospital, nursing facility or intermediate care facility. Benefit Provided: fospice Authorization: I other Amount Limit: I None Scope Limit: Source: I I state Plan l 905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: I lsee below Hospice is a program of care and support for beneficiaries who are terminally ill. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefits are subject to an enrollment determination process. Terminally ill beneficiaries have the option to enroll in a hospice program if their life expectancy is 6 months or less, as determined by a physician and the Hospice Medical Director. For beneficiaries under age 21, in accordance with Section 2302 of the Affordable Care Act, hospice care for children concurrent with curative treatment of the child's terminal illness is covered. Benefit Provided: jPodiatry -Other Licensed Practitioners Authorization: I None Amount Limit: I None Sc;_,.! Limit: Source: J lstate Plan l 905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: I INone Services are limited to those necessary to diagnose and/or treat illness, injury, the prevention of disability, or services provided to patients suffering from specific systemic diseases for which self-treatment would be hazardous. 11 Remove I 11 :i('trµove I I I I I I TN No: 15-1000 Michigan ABP5 Page 3 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmar1$...P,lan: I ,.. Benefit Provided: !Tobacco Cessation Treatment Authorization: IN one Amount Limit: INone Scope Limit: --· Source: I !state Plan l 905(a) - Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None 'Face-to-face tobacco cessation counseling services must be performed by or under the supervision of a physician or other health care professional licensed under state law. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: I Benefit Provided: !cert. Nurse Anesesth -Other Licensed Practitioners Authorization: INone Amount Limit: INone Scope Limit: Source: I I state Plan l 905(a) Provider Qualifications: I !Medicaid State Plan -Duration Limit: I !None 'Services are limited to those provided on an inpatient or outpatient basis and reimbursement is directed through to the provider or the provider's employer. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: I Benefit Provided: bmily Planning Services & Supplies Authorization: IN one Amount Limit: IN one Source: I !state Plan 1905(a) Provider Qualificmie.-:s: I !Medicaid State Plan Duration Limit: I INone - 1 1 a\jjt.'l:v.• "':':.i:r•,J•. ii 11 .:\,move I I I I I 1 1 ·Remove I I I I I I I I TN No: 15-1000 Michigan ABP5 Page 4 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

•••••••••••••mmmmim111111m11111111111111111111·,·/·1·,1;··1· 11111111•••••••••••••,:...,-:'ll,.\ ... ! b..'b.·,
 Alternative Benefit Plan Scope Limit: Family p!ltn.ning services include any medically approved means of voluntarily preventing & delaying pregnancy, including diagnostic evaluation, drugs, and supplies. Infertility treatment is not a covered benefit. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Source: !Chiropractic Services-Other Licensed Practitioners I !state Plan 1905(a) Authorization: Provider Qualifications: Authorization required in excess of limitation I \Medicaid State Plan Amount Limit: Duration Limit: I Is visits per calendar year I INone Scope Limit: Chiropractic services are limited to spinal manipulation. Benefit includes one set of spinal x-rays per beneficiary, per year. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: !Psychologists - Other Licensed Providers Authorization: IN one Amount Limit: 120 visits per calendar year Scope Limit: Source: I !state Plan I 905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None !Services are limited to those necessary to diagnosis and/or treat behavioral health disorders within the Psychologist's scope of practice as defined by State law. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: .; Benefit Provided: Source: !social Workers - Other Licensed Providers / lstate Plan l 905(a) ·- .... I Remove I 11 Remove I I I I 11 Remove I I I I I I . TN No: 15-1000 Michigan ABP5 Page 5 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Authorization: IN one Amount Limit: 120 visits per calendar year Scope Limit: Alternative Benefit Plan Provider Qualifications: I !Medicaid State Plan Duration Limit: I INone I Services are limited to those necessary to diagnosis and/or treat behavioral health disorders within the Social Worker's scope of practice as defined by State law. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Source: !Professional Counselors - Other Licensed Providers I I state Plan 1905(a) Authorization: I None Amount Limit: 120 visits per calendar year Scope Limit: Provider Qualifications: I !Medicaid State Plan Duration Limit: I INone I Services are limited to those necessary to diagnosis and/or treat behavioral health disorders within the Professional Counselor's scope of practice as defined by State law. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: 11 13;mv, i I I I 11 ?!-oy: I I I I I dd I . TN No: 15-1000 Michigan ABP5 Page 6 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

, ... ____________________ _ s .!:e ... - Alternative Benefit Plan \ Essential Health Benefft' Emergency services Benefit Provided: !Emergency Services -Other Medical Care Authorization: I None Amount Limit: INone Scope Limit: Source: ! I state Plan I 905(a) ..... - Provider Qualifications: \ !Medicaid State Plan Duration Limit: I !None !Benefit is limited to services that are necessary to evaluate or stabilize an emergency medical condition. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: I Benefit Provided: Source: !Emergency Transp./ Ambulance - Other Medical Care \ I state Plan I 905(a) Authorization: Provider Qualifications: IN one \ !Medicaid State Plan Amount Limit: Duration Limit: I None \ INone Scope Limit: !Benefit is limited to services that are necessary to evaluate or stabilize an emergency medical condition. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: I Benefit Provided: !urgent Care Services - Clinics Authorization: IN one Amount Limit: I None Scope Limit: Source: I I state Plan I 905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: ·11None -·- !Benefit is limited to unscheduled diagnosis and treatment of illnesses for ambulatory beneficiaries requiring immediate medical attention for non-life-threatening conditions. Collapse All O l I Remove I I I ! I 11 Remove I I I I I I I I I . TN No: 15-1000 Michigan ABP5 Page 7 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base ( enchmark plan: I I :Q:eino:\t' ,,1 . TN No: 15-1000 Michigan ABP5 Page 8 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

I!] Alternative Benefit Plan Essential Health Benefit 3: Hospitalization ... Collapse All D Benefit Provided: lrnpatient Hospital Services Authorization: !Prior Authorization Amount Limit: !None Scope Limit: Source: ! I state Plan 1905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None Services are covered when furnished by a certified hospital under the direction of a physician. Laboratory and radiology services performed as routine procedures or physician standing orders are excluded. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Medical, surgical, and rehabilitation inpatient services: elective admissions, readmissions, and transfers for inpatient hospital services must be authorized through the Admissions and Certification Review Contractor. Transplant Services are covered and certain transplant procedures require prior authorization. Admissions and continued stays for rehabilitation units and freestanding rehabilitation hospitals require prior authorization. ! I Remove I I I I Add I . TN No: 15-1000 Michigan ABP5 Page 9 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

l' . Alternative Benefit Plan Essential Health qt 4: Maternity and newborn care Benefit Provided: !Maternity Care - Physician Services Authorization: IN one Amount Limit: IN one Scope Limit: IN one Source: ..... - f I state Plan 1905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: !Benefit includes physician services related to maternity care, including prenatal care, delivery related services, and postpartum care. Benefit Provided: !Maternity Care - Inpatient Hospital Services Authorization: I None Amount Limit: IN one Scope Limit: Source: I !state Plan l 905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: I INone j Services are covered when furnished by a certified hospital under the direction of a physician. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: !Benefit includes inpatient hospital services related to maternity care, including prenatal care, delivery related services, and postpartum care. Benefit Provided: jMaternity Care- Outpatient Hospital Services Authorization: INone Amount Limit: IN one Scope Limit: Source: I !state Plan 1905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None !Benefit includes outpatient hospital services related to maternity care, including prenatal care, delivery related services, and postpartum care. Collapse All D 11 Remi:rv:e. I I I I I 11 l.rpye c-' ;j I I I I I I I I I TN No: 15-1000 Michigan ABP5 Page 10 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base Menchmark plan: • I Benefit Provided: Source: !Nurse Midwife Services Authorization: !None Amount Limit: !None Scope Limit: ' I I state Plan I 905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None The nurse midwife must have an alliance agreement that provides a safe mechanism for physician consultation, collaboration and referral. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Services include family planning, limited laboratory work, minor gynecological services, and maternity care for normal uncomplicated deliveries. The scope of nurse-midwifery involves the independent management of care of essentially normal pregnancies. I: . :R:eiµove I 11 . f:I .einpv I I I I Add I

TN No: 15-1000 Michigan ABP5 Page 11 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Essential Health Benefit 5:d',1ental health and substance use disorder services including ‡ behavioral health treatment Collapse All D Benefit Provided: Source: 'ˆM _ e _ n _ t_al _ lB _ e _ h _ a _ v _ io _ r _ al _ H _ ea _ l _ th _ - _ I _ np _ a _ t _ ie _ n _ t _H _ o _ sp _ i _ ta _ l_S _ e _ rv _ ._‰j j state Plan 1905( a) Authorization: Provider Qualifications: 'ŠO_t _ h _ er ________________ ___,11 ‹M_ed _ i _ c _ a _ id _ S_t _ a _ te _ P _ l _ a _ n ___________ __,! Amount Limit: Duration Limit: lŒN_o _ n _ e ________________ I !None Scope Limit: Services are covered when furnished by a certified hospital under the direction of a physician. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: P IHPs are responsible for inpatient psychiatric hospital admission authorizations/certifications. I Reimbursement will be excluded for services provided to individuals who are inpatients of an IMD. Benefit Provided: Source: lŽM _ en _ t _a _ llB _ eh _ a_v _ io _ r _ a _ l H_ea _ l _ th _ - _R _ eh _ a _ b _ il _ it _a _ ti _ on _ S _ e _ rv _ ic _ e _ s _ __,11 State Plan 1905( a) Authorization: Provider Qualifications: 'O _ t _ he _ r ________________ j jMedicaid State Plan Amount Limit: Duration Limit: lŽN _ o _ n _ e ________________ ___,! INone Scope Limit: Services must be provided under the direction of a physician and delivered according to a physician­ approved plan of service, under client services management, and by staff meeting appropriate professional qualifications. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Mental health outpatient rehabilitation services include diagnosis and evaluation, medication monitoring and administration, crisis intervention, individual group, and/or family therapy; behavioral management and occupational therapy. Mental health outpatient-partial hospitalization services: 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, in a licensed setting. PIHPs are responsible for all authorizations and continuing stay reviews. Benefit Provided: Source: 's _ u _ b _ st _ a _ nc _ e _ U _ se _ D _ is _ o _ rd _ e _ r _ - _ In _ p_a _ ti _ en _ t _ H _ o _ s _ p _ it _ a _ l _se _ rv _ ic _ e _ __,! lstate Plan 1905( a) " TN No: 15-1000 Michigan ABP5 Page 12 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Authorization: INone Amount Limit: I None Scope Limit: Provider Qualifications: I !Medicaid State Plan Duration Limit: I INone Medically necessary acute care substance abuse detoxification in the inpatient hospital setting is covered. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Admission to an acute care setting for a diagnosis of SUD must meet medical necessity criteria as reflected in the physician's orders and patient care. Once the beneficiary's condition is stabilized, he or she must be referred to an appropriate treatment service. Reimbursement will be excluded for services provided to individuals who are inpatients of an IMD. Benefit Provided: !Substance Use Disorder -Rehabilitation Services Authorization: I other Amount Limit: IN one Scope Limit: Source: I I state Plan 1905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None The program covers medically necessary rehabilitation services for persons with a chemical dependency diagnosis. Medical necessity is documented by physician referral or approval of the treatment plan. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Substance Abuse Treatment Programs must meet program criteria to provide services that include residential sub-acute detoxification, residential rehabilitation, intensive outpatient programs (IOP) and/or individual or group counseling. Detoxification, rehabilitation, and IOP require prior authorization. Reimbursement will be excluded for services provided to individuals who are inpatients of an IMD. Opiate-dependent beneficiaries may be provided approved pharmacological chemotherapy as an adjunct to a treatment service. Provision of such services must meet program criteria. 11 RemoNe I I 11 Remove I I I I Add I

TN No: 15-1000 Michigan ABP5 Page 13 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Essential Health Benefit 6: Prescription drugs Benefit Provi@sJ: 'f • .,. • Coverage is at least the greater of one drug in each U.S. Pharrrracopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark. Prescription Drug Limits (Check all that apply.): Authorization: Provider Qualifications: IZl Limit on days supply I I Atate licensed D Limit on number of prescriptions IZl Limit on brand drugs IZl Other coverage limits IZl Preferred drug list Coverage that exceeds the minimum requirements or other: I The State of Michigan's ABP prescription drug benefit is the same as under the approved Medicaid state plan for prescribed drugs. TN No: 15-1000 Michigan ABP5 Page 14 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Essential Health Benefit 7: Rehabilitative and habilitative services and devices Collapse All D Benefit Provi®d; !Rehabilitation Services: Outpt. Hospital Services Authorization: Authorization required in excess of limitation Amount Limit: I See below Scope Limit: Source: J lstate Plan I 905(a) Provider Qualifications: J IMedicaid State Plan Duration Limit: I lsee below 9,- Rehabilitative therapy services must be either restorative or specialized maintenance programs to be covered. Therapy must be ordered, in writing, by a physician or other Medicaid approved licensed practitioner within the scope of their practice. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Rehabilitative physical therapy and occupational therapy are each limited to 144 units (15 minute increments) per 12 month consecutive period. Speech therapy services in the outpatient setting are limited to 36 visits in a 12 month consecutive period. Outpatient rehabilitative services also includes medically necessary diabetic patient education and services for persons with neurological damage per program criteria. Additional apprqved state plan sources for outpatient rehabilitation services include 1905(a)(5); 1905(a)(7); and 1905(a)(13) respectively. Benefit Provided: !Habilitative Services -Outpatient Hosp. Services Authorization: Authorization required in excess of limitation Amount Limit: lsee below Scope Limit: Source: J lother state-defined Provider Qualifications: I !Medicaid State Plan Duration Limit: I !see below Habilitative therapy services include those that help a person keep, learn or improve skills and functioning for daily living. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Habilitative physical therapy and occupational therapy are each limited to 144 units ( 15 minute increments) per 12 month consecutive period. Speech therapy seryjces in the -.}Utpatient setting are limited to 36 visits in a 12 month consecutive period. Benefit Provided: Source: !Home Health Svcs.-Med Supplies, Equip, Appliances J lstate Plan 1905(a) 11 Remove I I I 11 Remove I I I I

TN No: 15-1000 Michigan ABP5 Page 15 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Authorization: I other Amount Limit: I varies Scope Limit: !Described below Provider Qualifications: I !Medicaid State Plan Duration Limit: I !varies Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Prior authorization ofDME is required except where exempted for selected diagnosis codes. Certain medical supplies may require prior authorization. All must meet medical necessity criteria. Benefit Provided: !Prosthetics and Orthotics; Eyeglasses, Hearing Aid Authorization: I other Amount Limit: I varies Scope Limit: !Described below Source: J lstate Plan 1905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: I I varies Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Certain medical supplies may require prior authorization. Eye glasses and contact lenses are covered benefits based upon specified medical necessity criteria; replacement lens coverage limits vary based on age and type of lens. Services also include hearing aids and auditory osseointegrated devices. Benefit Provided: Source: !Nursing Facility Services -Other Medical Service J lstate Plan l 905(a) Authorization: Provider Qualifications: !Prior Authorization J IMecticaid State Plan Amount Limit: Duration Limit: IN one J INone Scope Limit: !This is intended to be a short-term rehabilitation benefit. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Eligibility determination based upon a Level I Preadmission Screening/annual Resident Review (PASARR); and a determination of medical/functional assessment using the Medicaid Nursing Facility 11 R$:mov:e I I I 11 Ret'n't>ve.-. I I I I I I I TN No: 15-1000 Michigan ABP5 Page 16 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

"'[' ___________________ _ ti. Alternative Benefit Plan Benefit Provided: S ource: . Remove aIH _ o _ m _ e _ H _ e _ a _ It _ h _ -R _ e_h _ a _ b ___________ J js tate Plan I 905(a) J j R1;:move Auth orization: Provider Qualifications: bA_ u_ t_h _o _ri_za_ t_io_ n_ r_e_q_u_ir_e_d _ince_x_ce_ s_s _o_f_I _imcita_ t_io_ ndde f'M.ced_ i_c_a1_'d_S_ t_a_te_P_ I_a_n gddgddgddgdh Amount Limit: Duration Limit: Lls_e_e_ b_e_Io_wddddddddddddddd--'11 -S_e_e_ b_e_Io_wdgddgddgddgddgdi S cope Limit: !Described below Other information reg arding this benefit, including the specific name of the source plan if it is not the b ase bench mark plan: Physical therapy and occupational therapy as provided by a h ome health agency are each limited to 24 visits per 60 days; additional services require prior auth orization. Add

TN No: 15-1000 Michigan ABP5 Page 17 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

 Essential Health Benefit 8: Laboratory services Benefit Proyided: !Laboratory Authorization: I other Amount Limit: IN one Scope Limit: Source: I I state Plan 1905(a) Provider Qualifications: I !Medicaid State Plan Duration Limit: / INone ·- Covered services include laboratory tests which are medically necessary for diagnosis and treatment of illness or injury when ordered by a physician or other licensed practitioner. Other information regarding this benefit, including the specific name of the source plan ifit is not the base benchmark plan: Screening or routine laboratory testing, except as specified for the Early and Periodic Screening, Collapse All D 11 R¢nj<l\i¢C I I I Diagnosis, and Treatment (EPSDT) Program or Preventive Medicine services, or by Medicaid policy, is not a benefit. A limited number of laboratory services require prior authorization. I ->.Ad I TN No: 15-1000 Michigan ABP5 Page 18 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan \ Essential Health Benefit 9: Preventive and wellness services and chronic disease management ::, Collapse All D The state/territory must provide, at a minimum, a broad range of preventive services including: "A" and "B" services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM). Benefit Provided: Source: !Preventive Services J IBase Benchmark Small Group 11 ·R;emo'.ve I Authorization: Provider Qualifications: IN one J IMedicaid State Plan I Amount Limit: Duration Limit: I see below J lsee below I Scope Limit: One preventive medicine visit per year; other preventive services as per recommended guidelines of the referenced authorities. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: "A" and "B" services recommended by the United States Preventive Services Task Force; Advisory Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM). The base-benchmark provides for the full range of preventive benefits as required under current federal requirements. I Add I

TN No: 15-1000 Michigan ABP5 Page 19 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

:;{ ..
Alternative Benefit Plan Essential Health Bp'it 10: Pediatric services including oral and vision care - Benefit Provided: Medicaid State Plan EPSDT Benefits Authorization: I other Amount Limit: I None Scope Limit: Source: "I state Plan l 905(a) - Provider Qualifications: I !Medicaid State Plan Duration Limit: I IN/A IEPSDT services are provided to beneficiaries under the age of 21. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: EPSDT services are provided as defined in section 1905 (r) (5) of the Social Security Act. Certain limited services may be provided by Intermediate School Districts, such as OT, PT, speech therapy, psychological counseling and social work services, physician and nursing care, personal care, and specialized transportation as identified in an Individualized Education Program (IBP). Religious non-medical health care nursing services and private duty nursing services may be prior authorized for beneficiaries under age 21. Dental services and blood lead follow-up services are covered. Collapse All O 11 ilem,ve ·1 I I I ,.;<9-\ .. ·. I TN No: 15-1000 Michigan ABP5 Page 20 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan O Other Covered Benefits from Base Benchmark Collapse All O

TN No: 15-1000 Michigan ABP5 Page 21 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan
Base Benchmark Benefits Not Covered due to Substitution or Duplication Collapse All D - Base Benchmark Benefit that was Substituted: Source: !Primary Care Provider Services -Duplication I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Primary Care Provider Services were bundled with Specialist/Referral Care and mapped to the "ambulatory patient services" EHB category. The bundled services are a duplication of physician services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Referral Care Services -Duplication I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit( s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Referral Care Services were bundled with Primary Care Provider services and mapped to the "ambulatory patient services" EHB category. The bundled services are a duplication of physician services and other licensed practitioner services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Outpatient Hospital Services-Duplication I Base Benchmark I I RemQYk Explain the substitution or duplication, including indicating the substituted benefit( s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Outpatient hospital services are mapped to the "ambulatory patient services" EHB category. The services are a duplication of outpatient hospital services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Home Health Care -Duplication I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Home health care services are mapped to the "ambulatory patient services" EHB category. The services are a duplication of Home health care services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Hospice -Duplication I Base Benchmark I I Rt11!t,ove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Hospice services are mapped to the "ambulatory patient services" EHB category. The services are a I duplication of hospice services from th;;) ex::,ling state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !services by Other Health Professional -Duplication I Base Benchmark TN No: 15-1000 Michigan ABP5 Page 22 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: I Rem-ove I Services by Other Health Professional (Podiatry) are mapped to the "ambulatory patient services" EHB category. The services are a duplication of podiatry services -other licensed practitioner- from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Medical Emergency Care -Duplication I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Medical emergency care is mapped to the "emergency services" EHB category. The services are a duplication of emergency services -other medical care- from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Emergency Ambulance Services -Duplication I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Emergency ambulance care is mapped to the "emergency services" EHB category. The services are a duplication of emergency transportation services -other medical care- from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: \urgent Care Services -Duplication I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Urgent care services are mapped to the "emergency services" EHB category. The services are a duplication of clinic services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: [Hospital Inpatient Care -Duplication I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 193 7 benchmark benefit(s) included above under Essential Health Benefits: Inpatient hospital care is mapped to the "hospitalization" EHB i,ategory. The services are a duplication of inpatient hospital services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Maternity and Newborn Care -Duplication I Base Benchmark I I Remove rxi:-... :n the substitution or duplication, including indicating the substituted benefit( s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Maternity and newborn care is mapped to the "maternity and newborn care" EHB category. The services are a duplication of physician, outpatient, and inpatient hospital services from the existing state Medicaid plan. TN No: 15-1000 Michigan ABP5 Page 23 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Source: !Mental Heal}p.cute lnpt. Hospitalization. -Dupl. I Base Benchmark I .. ~move I -.. Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section I 937 benchmark benefit(s) included above under Essential Health Benefits: Mental Health acute inpatient hospitalization is mapped to the "mental health and substance use disorder services" EHB category. The services are a duplication of psychiatric inpatient hospital services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !outpatient Rehabilitation - Duplication I Base Benchmark I I Rewove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Outpatient Rehabilitation services are mapped to the "rehabilitative and habilitative services and devices" EHB category. The services are a duplication of Rehabilitation Services: Outpt. Hospital Services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Durable Medical Equipment and Supplies- Dupl. I Base Benchmark I I Re1n9:ve Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section I 937 benchmark benefit(s) included above under Essential Health Benefits: Durable Medical Equipment and Supplies are are mapped to the "rehabilitative and habilitative services and devices" EHB category. The services are a duplication of Home Health Services.-Med Supplies, Equip, Appliances from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Prosthetics and Orthotics - Duplication r-Base Benchmark I Remove I Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section I 937 benchmark benefit(s) included above under Essential Health Benefits: Prosthetics and Orthotics are mapped to the "rehabilitative and habilitative services and devices" EHB category. The services are a duplication of Prosthetics and Orthotics from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !chiropractic Services - Duplication I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section I 937 benchmark benefit(s) included above under Essential Health Benefits: 'Chiropractic Services are mapped to the "ambulatory patient service" EHB category. The services are a duplication of Chiropractic Services-Other Licensed Practitioners from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: I Skilled Nsg. Facility - Facility Rehab. Care-Dupl. I Base Benchmark TN No: 15-1000 Michigan ABP5 Page 24 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: ·- I Remove I Skilled Nursing Facility - Facility Rehabilitation services are mapped to the "rehabilitative and habilitative services and devices" EHB category. The services are a duplication of nursing facility services -other medical services- from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Laboratory Services - Duplication I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Laboratory services are mapped to the "laboratory services" EHB category. The services are a duplication of laboratory services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Tobacco Cessation Treatment - Duplication I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Tobacco Cessation Treatment is mapped to the "ambulatory patient services" EHB category. The services are a duplication of Tobacco Cessation Treatment from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !other Services Provided by Health Profess. -Duplic I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Other services provided by health professionals ( e.g. allergy testing, diabetic services, pain management, etc.) is mapped to the "ambulatory patient services" EHB category. These services are a duplication of physician services, outpatient hospital services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: IHome Health Care -Duplication I Base Benchmark I I Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Home Health services are mapped to the are mapped to the "ambulatory patient services" EHB category. The services are a duplication of home health services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Family Planning/Reproductive Services -Duplication I Base Benchmark l_Remiii] ,(,: Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Family Planning/Reproductive Services is mapped to the "ambulatory patient services" EHB category. The services are a duplication of Family Planning Services and supplies from the existing state Medicaid plan.

TN No: 15-1000 Michigan ABP5 Page 25 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Source: !Referral Care Services -Duplication I Base Benchmark I R{Ji\iive I Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Referral Care Services is mapped to the "ambulatory patient services" EHB category. The services are a duplication of Certified Nurse Anesthetists -Other Licensed Practitioner services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Nurse Midwife Services -Duplication I Base Benchmark I I 'Zemo:ve Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 193 7 benchmark benefit(s) included above under Essential Health Benefits: Nurse Midwife Services is mapped to the "maternity and newborn care" EHB category. The services are a duplication of Nurse Midwife services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: !Mental Health Outpatient Treatment -Duplication I Base Benchmark I ,\ftov I Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Mental Health Outpatient Treatment services are mapped to the "mental health and substance use disorder services" EHB category. The services are a duplication of mental/behavioral health outpatient - rehabilitation services from the existing state Medicaid plan. Base Benchmark Benefit that was Substituted: Source: I substance Abuse Services - Duplication I Base Benchmark I R[move I Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Substance Abuse Services covering inpatient hospital services are mapped to the "mental health and substance use disorder services" EHB category. Substance Abuse Services covering outpatient treatment is also mapped to the "mental health and substance use disorder services" EHB category. These services are a duplication of Substance use disorder -Inpatient Hospital Service & Outpatient Services- Rehabilitation from the existing state Medicaid plan. I J\dd I TN No: 15-1000 Michigan ABP5 Page 26 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

-=-· ,,,r, _____________________ _
 Alternative Benefit Plan D Other Base Benchmar nefits Not Covered Collapse All D

TN No: 15-1000 Michigan ABP5 Page 27 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

lzsl •••••••••••••••••• ll;,.,1,."""' Alternative Benefit Plan Other 1937 Covered Benefits that are not Essential Health Benefits Collapse All D Other 1937 Benefit Provided: -·' !Dental Services Authorization: I other Amount Limit: I varies Scope Limit: Source: Section 1937 Coverage Option Be"Y-chmark Benefit I Package Provider Qualifications: I !Medicaid State Plan Duration Limit: I !varies Preventive dental services are covered every six months. Radiograph limits vary based on type of view ( eg. bitewing, panorex, etc.). Other: Dental treatment for adults, including diagnostic, therapeutic, and restorative care, are covered for conditions relating to a specific medical problem. All prosthodontics (dentures) require prior authorization. Other 1937 Benefit Provided: !vision/Optometrist Services Authorization: I other Amount Limit: I varies Scope Limit: Source: I Section 1937 Coverage Option Benchmark Benefit Package Provider Qualifications: I !Medicaid State Plan Duration Limit: j jvaries Routine eye exam once every two years; non-routine exams limited to those services relating to eye trauma and eye disease and low vision evaluations, services and aids (which must be prior authorized). Other: I I Vision/Optometrist Services are covered for adults. Certain services and supplies may be subject to meeting stipulated criteria and/or prior authorization. Other 1937 Benefit Provided: Source: !Personal Care Services I Section 1937 Coverage Option Benchmark Benefit Package Authorization: Provider Qualifications: IPrior Authorization ] !Medicaid State Plan · Amount Limit: Duration Limit: I varies I !varies I Remoy I I Remove I I I I TN No: 15-1000 Michigan ABP5 Page 28 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Scope Limit:
Requires certification by a licensed health care professional and a plan of care to determine medical necessity for services. Other: Personal Care Services, under the Home Help Program, include assistance with eating, toileting, bathing, grooming, dressing, transferring, self-administered medication, meal preparation, shopping/errands, laundry and light housekeeping for beneficiaries requiring physical help to perform activities of daily living. Program eligibility criteria applies. This benefit is included for individuals in accordance with 42 CFR 440.3 IS(f). Other 1937 Benefit Provided: !Extended Services to Pregnant Women Authorization: I other Amount Limit: 1 assessment visit; up to 9 professional visits Scope Limit: Source: I Section 1937 Coverage Option Benchmark Benefit Package Provider Qualifications: I !Medicaid State Plan Duration Limit: I lvaries Services must be related to or associated with maternal and infant health conditions that may complicate pregnancy. Other: Maternal Infant Health Plan (MIHP) services are preventive health services that include social work, nutrition counseling, nursing services (including health education and nutrition education) and beneficiary advocacy services as provided by program criteria. Prior authorization is generally not required. Other 1937 Benefit Provided: !Nursing Facility Services - Long Term Care Authorization: !Prior Authorization Amount Limit: IN one Scope Limit: Source: I Section 1937 Coverage Option Benchmark Benefit Package Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None Period of covered services is the minimum period necessary in this type of facility for proper care and treatment ofthe patient; benefit includes bed and board; nursing care; routine PT/OT/SL T consisting of repetitive services to maintain function. Other: Eligibility determination based upon a Level I Preadmission Screening/ Annual Resident Review (PASARR); and a determination of medical functional assessment using the Medicaid Nursing Facility Level of Care Determination (LOCO). This benefit is included for individuals in accordance with 42 CFR 440.3 lS(f). I ·Remove I I Remove I I I I Remove I I I

TN No: 15-1000 Michigan ABP5 Page 29 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

\ 'l . Alternative Benefit Plan Other 193 7 Benem'f!rovided: !clinic Services Authorization: I other Amount Limit: INone Scope Limit: I see scope limit below. Other: Source: i Section 1937 Coverage Option Benchmark Benefit Package ...... - Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None Preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services are covered with the same limitations as services provided in the practitioner's office, when furnished to an outpatient by or under the direction of a physician or dentist in a facility which is not part of a hospital but which is organized and operated to provide medical care to outpatients. Prior authorization is generally not required. Mental Health Clinic Services are covered benefits when provided under the auspices of an approved mental health clinic. Other 1937 Benefit Provided: IReg./Lic. Dental Hygienists -Other Licensed Pract. Authorization: I other Amount Limit: I None Scope Limit: Source: I Section 1937 Coverage Option Benchmark Benefit Package Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None !Limited to services rendered on behalf of an organization, clinic or group practice. Other: Covered services are limited to those allowed under the RDH's scope of practice as defined by State law. Prior authorization is generally not required. Other 1937 Benefit Provided: !Behavioral Health Targeted Case Mgmt Services Authorization: I other Amount Limit: INone Source: I Section 1937 Coverage Option Benchmark Benefit Package Provider Qualifications: I IMe<licaid State Plan Duration Limit: I INone I ,Remove I I I I I Ilethove I I I : I TN No: 15-1000 Michigan ABP5 Page 30 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Scope Limit: Targeted group populations as defined in the state plan specify services and prler qualifications. Other: Services include comprehensive client assessment; care/services plan development; linking/coordination of services; reassessment/follow-up; monitoring of services as defined by program. Prior authorization is generally not required. Other 1937 Benefit Provided: jPharmacists -Other Licensed Practitioners Authorization: I other Amount Limit: INone Scope Limit: Source: I Section 1937 Coverage Option Benchmark Benefit Package Provider Qualifications: I !Medicaid State Plan Duration Limit: I INone Limited to administration of vaccines and toxoids as allowed by applicable state authority. Other: Prior authorization is generally not required. Other 1937 Benefit Provided: IICF/IID Services Authorization: !concurrent Authorization Amount Limit: I None Scope Limit: Source: I Section 1937 Coverage Option Benchmark Benefit Package Provider Qualifications: I !Medicaid State Plan Duration Limit: I !None Service is provided for individuals who are developmentally disabled (or for persons with related conditions) in properly certified and/or licensed public or private institutions (or distinct part thereof) for the developmentally disabled. Other: Intermediate care services are provided based on the level of care appropriate to the patient's medical needs. Admission to an intermediate care facility must be upon the written direction of a physician, who must p ... riodically recertify the need for cat;;;;. Admission must also be prior authorized by the Michigan Department of Community Health or its designee. The period of covered services is the minimum period necessary for the proper care and treatment of the patient. Services regularly provided in these settings are in compliance with the provisions of 42 CFR 440.150 and include health related and programmatic care, supervised personal care, as well as room and board. I Remove I I Remove I I I I llemove I I I

TN No: 15-1000 Michigan ABP5 Page 31 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Other 1937 Benefit Provided: !Program of All-Inclusive Care for Elderly (PACE) Authorization: I other Amount Limit: lsee below Scope Limit: Source: Section 1937 Coverage Option Benchmark Benefit I Package Provider Qualifications: I !Medicaid State Plan Duration Limit: I lsee below PACE services are provided to beneficiaries age 55 or older meeting program criteria. Other: The State of Michigan's ABP PACE Program benefit is the same as under the approved Medicaid state plan for this benefit. This benefit is included for individuals in accordance with 42 CFR 440.315([). Other 1937 Benefit Provided: !Rehabilitation -Mental Health Crisis Residential Authorization: IPrior Authorization Amount Limit: I see below Scope Limit: Source: I Section 1937 Coverage Option Benchmark Benefit Package Provider Qualifications: I !Medicaid State Plan Duration Limit: I !see below irIHPs are responsible for all authorizations and continuing stay revieis. Treatment services must be clinically-supervised by a psychiatrist. The program must include on-site nursing services. Other: Short-term alternative to inpatient psychiatric services for beneficiaries experiencing an acute psychiatric crisis when clinically indicated. Services may only be used to avert an inpatient psychiatric admission, or to shorten the length of an inpatient stay. Services must be provided to beneficiaries in licensed crisis residential foster care or group home settings not exceeding 16 beds in size. Homes/settings must have appropriate licensure from the state and must be approved by MDCH to provide specialized crisis residential services. Covered crisis services include: psychiatric supervision; therapeutic support services; medication management/stabilization and education; behavioral services; milieu therapy; and nursing services. Reimbursement will be excluded for services provided to individuals who are inpatients of an IMD. Other 1937 Benefit Provided: IMentai ttealth Outpatient Community Support Authorization: I other Amount Limit: I varies Source: I Section 1937 Coverage Option Benchmark Benefit Package Provider Qualifications: I !Medicaid State Plan Duration Limit: I !varies I Remove I I I I ·Rem,oye I I I I I TN No: 15-1000 Michigan ABP5 Page 32 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Scope Limit: ABP Services are limited to individual program criteria as identified under the c:tpproved Medicaid state plan. Other: Mental Health Outpatient Community Support Services as included the following services: • Assertive Community Treatment: Assertive Community Treatment (ACT) is a set of intensive clinical, medical and psychosocial services provided by a mobile multi-disciplinary treatment team. Utilization of ACT services in high acuity conditions/situations allows beneficiaries to remain in their community residence and may prevent the use of more restrictive alternatives which may be detrimental to a beneficiary's existing natural supports and occupational roles. (This benefit is described in the current approved state plan as Mental Health Community Rehabilitation Services, Supplement to attachment 3.1-A, pg. 27a.) • Clubhouse Psychosocial Rehabilitation Programs: Clubhouse Psychosocial Rehabilitation Programs - a program in which the beneficiary, with staff assistance, is engaged in operating all aspects of the clubhouse. Elements of the program include: Member-choice involvement, informal setting, program structure and services, ordered day, employment services and educational support, member supports, and social supports. (This benefit is described in the current approved state plan as Mental Health Psychosocial Rehabilitation Program, Supplement to attachment 3.1-A, pg. 27c.) • Intensive Crisis Stabilization: Intensive Crisis Stabilization provides structured treatment and support activities provided by a multidisciplinary team. Component services include: Intensive individual counseling/psychotherapy; Assessments (rendered by the treatment team); Family therapy; Psychiatric supervision; and Therapeutic support services by trained paraprofessionals. (This benefit is described in the current approved state plan as Intensive/Crisis Residential Services, Supplement to attachment 3.1-A, pg. 27h.) Other 1937 Benefit Provided: !Substance Use Disorder Residential Services Authorization: !Prior Authorization Amount Limit: [varies Scope Limit: Source: I Section 1937 Coverage Option Benchmark Benefit Package Provider Qualifications: I !Medicaid State Plan Duration Limit: I !varies Medically necessary rehabilitation services for persons with a chemical dependency diagnosis as documented by physician referral/or approval of the treatment plan. Othi>r: - · Substance Abuse Treatment Programs must meet program criteria to provide services that include residential sub-acute detoxification, residential rehabilitation, intensive outpatient programs (IOP) and/or individual or group counseling. Detoxification, rehabilitation, and IOP require prior authorization. Reimbursement will be excluded for services provided to individuals who are inpatients of an IMD. I Remove I I Remove I I I TN No: 15-1000 Michigan ABP5 Page 33 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan Other 1937 Benefit Provided: lsubst Use „der Sub-Acute Detox Services Authorization: jconcurrent Authorization Amount Limit: Source: I Section 1937 Coverage Option Benchmark Benefit Package - Provider Qualifications: I !Medicaid State Plan Duration Limit: I I varies I lvaries -i Scope Limit: Limited to the stabilization of the medical effects of the withdrawal and to the referral to necessary ongoing treatment and/or support services. Licensure as a sub-acute detoxification program is required. Other: Detoxification can take place in both residential and outpatient settings, and at various levels of intensity within these settings. Client placement must be based on ASAM Patient Placement Criteria and individualized determination of client need. Reimbursement will be excluded for services provided to individuals who are inpatients of an IMO. Other 1937 Benefit Provided: !Behavioral Health Community Based Services 1915(i) Authorization: I other Amount Limit: I varies Scope Limit: Source: I Section 1937 Coverage Option Benchmark Benefit Package Provider Qualifications: I !other Duration Limit: I !varies - - I I I - Services are limited to individual program criteria and are based on a person centered planning process and available for Mental Health and Substance Use Disorders. Other: For any Home and Community Based Services benefits as permitted in 1915(i) in ABP5, the state assures that: I. The service(s) are provided ip. settings that meet HCB setting requirements; 2. The services(s) meet the person-centered service planning requirements; 3. Individuals receiving these services meet the state-established needs-based criteria that are not related solely to age, disability, or diagnosis, and are less stringent than criteria for entry into institutions. Services can be accessed as needed, even if the individuals have needs that are below institutional level of care. fhe Medicaid state plan defines provider qualifications for all but the fol!:,·., ing: aides, mental h._.tith professionals, peer support specialists, psychologists, qualified intellectual disability professionals, qualified mental health professionals, social workers, and substance abuse treatment specialists. All providers must be: at least 18 years of age; able to prevent transmission of communicable disease; able to communicate expressively and receptively in order to follow individual plan requirements and beneficiary-specific emergency procedures, and to report on activities performed; and in good standing with the law (i.e., not a fugitive from justice, a convicted felon who ;c :+her 11nder jurisdiction or whose I ·:l\,ihove I TN No: 15-1000 Michigan ABP5 Page 34 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

•••••••••••••••u••••••••••••••••,,· .. - •••••••••••••••••!i:,,.\,,.b.""'-#
 Alternative Benefit Plan ltelony relates to the kmct ot ctuty to be pertormect, or an 111ega1 alien). Licensed protess1onals must act within the scope of practice defined by their licenses. "Supervision" is defined by the Occupational Regulations Section of the Michigan Public Health Code at MCL§333.16109 and, as approprTate, in the administrative rules that govern licensed, certified and registered professionals. Training, and fieldwork experience may be required as defined by the Michigan Department of Community Health. BEHAVIORAL HEAL TH COMMUNITY BASED SUPPORTS AND SERVICES: • Assistive Technology: Assistive technology is an item or set of items that enable the individual to increase his ability to perform activities of daily living with a greater degree of independence than without them; to perceive, control, or communicate with the environment in which he lives. Assistive technology items are not available through other Medicaid coverage or through other insurances. These items must be specified in the individual plan of service. All items must be ordered by a physician on a prescription. • Community Living Supports: Community Living Supports are used to increase or maintain personal self­ sufficiency, facilitating an individual's achievement of his goals of community inclusion and participation, independence or productivity. Community Living Supports may be provided in the participant's residence or in community settings. • Enhanced Pharmacy: Enhanced pharmacy items are physician-ordered, nonprescription "medicine chest" items as specified in the individual's plan of service. Enhanced pharmacy needs must have documented evidence that the item is not available through Medicaid or other insurances, and is the most cost effective alternative to meet the beneficiary's needs. • Environmental Modifications: Environmental Modifications are physical adaptations to the beneficiary's own home or apartment and/or work place. Environmental modifications must have documented evidence that the modification is the most cost-effective alternative to meet the beneficiary's need/goal based on the results of a review of all options. • Family Support and Training: 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. • Housing Assistance: Housing assistance is assistance with short-term, interim, or one-time-only expenses for beneficiaries transitioning from restrictive settings and homelessness into more independent, integrated living arrangements. Housing assistance coverage includes assistance with utilities, insurance, and moving expenses; limited term or temporary assistance with living expenses for beneficiaries transitioning from restrictive settings and homelessness, interim assistance with utilities, insurance or living expenses; home maintenance when, without a repair, the individual would be unable to move there, or if already living there, would be forced to leave for health and safety reasons. • Peer Delivered or Operated Support Services: Peer-delivered or peer-operated support services are programs and services that provide individuals with Q!j)portunitie:; to learn and share coping skills and strategies, move into more active assistance, and to build and/or enhance self-esteem and self-confidence. Peer delivered/specialist services provide support and assist beneficiaries to achieve community inclusion, participation, independence, recovery, resiliency and/or productivity. • Drop In Centers: Peer-Run Drop-In Centers provide an informal, supportive environment to assist beneficiaries with mental illness in the recovery process. Peer-Run Drop-In Centers provide opportunities to learn and share coping skills and strategies, to move into more active assistance and away from passive

TN No: 15-1000 Michigan ABP5 Page 35 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

Alternative Benefit Plan lbenehc1ary roles and identities, and to build and/or enhance self-esteem and self-conttdence. • Prevention Direct Service Models: Prevention-direct service models are prugnuns using individual, family I, tBre I and group interventions designed to reduce the incidence of behavioral, emotional or cognitive dysfunction. Prevention direct service models reduce the need for individuals to seek treatment through the public mental health system. This service includes the programs of Child Care Expulsion Prevention, School Success Programs, Children of Adults with Mental Illness/Integrated Services, Infant Mental Health when not enrolled as a Home-Based program, and Parent Education. • Respite Care Services: Respite care services are intended to assist in maintaining a goal ofliving 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. • Skill Building Assistance: Skill-building assistance consists of activities identified in the individual plan of services and designed by a professional within his/her scope of practice that assist a beneficiary to increase his economic self-sufficiency and/or to engage in meaningful activities such as school, work, and/ or volunteering. The services provide knowledge and specialized skill development and/or support. Skill building services may be provided in the beneficiary's residence or in community settings. • Support and Service Coordination: Supports and service coordination are functions performed by a supports coordinator, supports coordinator assistant, services and supports broker, or otherwise designated representative of the PIHP that include assessing the need for support and service coordination. Supports and service coordination includes 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 the Medicaid Health Plan, Medicaid fee-for- service, or other health care providers. • Supported I Integrated Employment Services: Employment services provide job development, initial and ongoing support services, and activities as identified in the individual plan of services that assist beneficiaries to obtain and maintain paid employment that would otherwise be unachievable without such supports. Employment support services are provided continuously, intermittently, or on a diminishing basis as needed throughout the period of employment. Supported/ integrated employment must be provided in integrated work settings where the beneficiary works alongside people who do not have disabilities. • Fiscal Intermediary Services: Fiscal Intermediary Services are services that assist the adult beneficiary, or a representative identified in the beneficiary's individual plan of services, to meet the beneficiary's goals of community participation and integration, independence or prqductivity while controlling his individual budget and choosing staff who will provide the services and supports identified in the IPOS and authorized by the PIHP. I Add I TN No: 15-1000 Michigan ABP5 Page 36 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

·•sr·-1111111------------------- §. Alternative Benefit Plan D Additional Covered BJts (This category of benefits is not applicable to the adult group under section 1902(a)(IO)(A)(i)(VIII) of the Act.) PRA Disclosure Statement Collapse All D 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 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. lfyou 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.20130814 TN No: 15-1000 Michigan ABP5 Page 37 of 37 Approval Date: 9/30/15 Effective Date: 9-1-15

_____________________________________________________________________________

Table of Contents State/Territory Name: Michigan State Plan Amendment (SPA) #: 16-0110: Eligibility Process This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) CMS 179 Form 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Chicago Regional Office 233 N. Michigan Suite 600 Chicago, Illinois 60601

January 11, 2019

Kathy Stiffler, Acting Medicaid Director Medical Services Administration Michigan Department of Health and Human Services 400 South Pine Street, P.O. Box 30479 Lansing, Michigan 48909-7979

ATTN: Erin Black

Dear Ms. Stiffler:

The Centers for Medicare & Medicaid Services (CMS) has completed its review of Michigan’s State Plan Amendment (SPA) 16-0110, Changes to Medicaid Application. This amendment proposes to revise the Michigan Bridges alternative online, and Michigan Department of Health and Human Services (MDHHS) paper applications used to apply for multiple human service programs.

We have received via email an updated S94 indicating the state’s use of an alternative application for multiple human services programs. We acknowledge the state attempted to upload the updated S94 to MMDL on January 11, 2019, but the upload to MMDL failed. We understand the state will correct this error as soon as possible after approval. This SPA is acceptable. Therefore, we are approving a revised version of the applications that were submitted with SPA 16-0110 with an effective date of March 1, 2016, and acknowledge Michigan implemented different versions of these applications prior to SPA approval.

Please note that accompanying the approval of SPA 16-0110 is an enclosed companion letter regarding the need for Michigan to make modifications to the Michigan Bridges online multi-benefits application and the MDHHS paper application. Michigan will implement revised alternative online and paper applications addressing CMS concerns by the dates listed in the companion letter. Michigan will provide updated dates for completion of outstanding changes within 60 days of approval of this SPA.

Ms. Stiffler Page 2

Enclosed for your records is an approved copy of the following State Plan Amendment:

 Transmittal #: 16-0110: Eligibility Process  Effective: March 1, 2016  Approved: January 11, 2019

If you have any questions, please contact Keri Toback at (312) 353-1754 or Keri.Toback@cms.hhs.gov.

Sincerely,

/s/

Ruth A. Hughes

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Cc: Jaqueline Coleman Erin Black

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Chicago Regional Office 233 N. Michigan Suite 600 Chicago, Illinois 60601

January 11, 2019

Kathy Stiffler, Acting Medicaid Director Medical Services Administration Michigan Department of Health and Human Services 400 South Pine Street, P.O. Box 30479 Lansing, Michigan 48909-7979

ATTN: Erin Black

Dear Ms. Stiffler:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) 16-0110, which was submitted to CMS on March 31, 2016. Our review of this submission included a review of the Michigan Bridges alternative online, and Michigan Department of Health and Human Services (MDHHS) paper applications used to apply for multiple human services.

Michigan is currently using interim Michigan Bridges alternative online, and MDHHS paper applications. Within 60 days of approval of this SPA, Michigan will provide updated dates indicating when it will implement revised alternative online and paper applications incorporating the changes listed below:

Michigan SPA 16-0110 Changes to Medicaid Application Companion Letter Exhibit 1

Necessary changes to the Online Application: Date by which changes will be completed (state to fill in) missing dates within 60 days of SPA approval): 1 The state will revise the instructions regarding providing a Social Security Number to align with the exceptions to not providing an Social Security Number at 435.910(h), and replace them with the following:

Michigan provided this new suggested text: A Social Security Number should be provided for all individuals applying, if the individual has one. If the individual does not have a Social Security Number, leave this box blank. If you need help applying for a Social Security Number call us at 855-276- 4627.

2 The state will remove instructions indicating that benefits may be reduced or denied to otherwise eligible individuals if a Social Security Number is not provided, and replace them with the following:

Michigan provided this new suggested text: A Social Security Number should be provided for all individuals applying, if the individual has one. If the individual does not have a Social Security Number, leave this box blank. If you need help applying for a Social Security Number call us at 855-276- 4627.

3 The application requests an individual’s primary race, and this is a required field when an applicant selects multiple races. The state indicates this questions is required due to requirements in the account transfer payload to send only one option for race. CMS has confirmed that the AT payload can accept multiple race options. Additionally, applicants may not be required to respond to questions about race/ethnicity. The state will remove the question asking for an applicant’s primary race.

4 The state will change the application to allow an applicant to indicate if he/she is a veteran or active duty member of the US military, in addition to the applicant’s spouse or parent.

5 The application provides an inaccurate definition of qualified non-citizen. The state will provide an accurate definition of “qualified non-citizen” to include the following: Lawful Permanent Resident (LPR/Green Card holder); Asylee; Refugee; Cuban/Haitian Entrant; Paroled into the U.S. for at least one year; Conditional Entrant Granted before 1980; Amerasians; Battered Spouse, Child and Parent; Iraqi/Afghan Special Immigrants ; Victim of Trafficking and his/her Spouse, Child, Sibling or Parent; Granted Withholding of Deportation or Withholding of Removal.

6

The state will confirm if it will make changes to the application to include instructions explaining which immigration statuses are considered lawfully present for the Federally Facilitated Exchange, or if it will revise the language in the instructions that limit eligible statuses to “qualified non-citizen” immigration statuses. A complete list of immigration statuses considered to be lawfully present, are found here: https://www.healthcare.gov/immigrants/immigration-status/

7 The state will remove questions asking if an individual is a Victim of Trafficking, a seasonal farmworker, and a migrant farmworker. January 26, 2019

8 The state has confirmed it has changed the application and marked as “optional” the questions asking if an individual is a victim of domestic violence. (Please provide date change was implemented, and documentation verifying this change.)

9 The state has explained the question asking whether an individual is a refugee/asylee on the Special Circumstances page is asked of anyone in the household, including applicants and non-applicant household members. Because applicants have an opportunity to indicate asylee/refugee status in the immigration eligibility section, the state will remove the question since it is not needed for eligibility or administration of the state plan, and individuals not seeking coverage for themselves who are included in an applicant’s or beneficiary’s household to determine eligibility of such applicant or beneficiary may not be required to provide information about their citizenship, nationality or immigration status.

10 The state confirmed that the question, “Does anyone in your household have a disability or a physical/emotional/mental condition?” will not be shown to non-applicants. January 26, 2019

11 Michigan confirmed that the question, “Was anyone in foster care when they turned 18?” will not be shown to non- applicants. January 26, 2019 12 Michigan confirmed the pregnancy due date question will be marked optional. January 26, 2019 13 “Is anyone currently enrolled in health coverage (even if not applying)” is not required for those not applying for coverage unless applicants are covered under those individuals’ plans. CMS understands that the state is using this question to ensure that dependent children, even if not applying, currently have coverage. As shown, this question is not narrowly tailored for this purpose. Michigan will share a draft of the modified question with CMS prior to implementing changes to the application, and will provide a timeline of when the changes will be implemented.

14 CMS recommends the state include on its application notice of fair hearing rights consistent with 42 CFR 431.206(c)(2), when the agency does not determine eligibility with

reasonable promptness required at 42 CFR 431.220(a)(1), within the 45/90 day timeframe consistent with 42 CFR section 435.912(c)(3). CMS is considering developing guidance and states may be required to implement these changes in the future.

Necessary changes to the Paper Application and Corresponding Information Booklet by Reference: Date by which changes will be completed (state to fill in):

15 The state will revise the instructions regarding providing a Social Security Number to align with the exceptions to not providing a Social Security Number at 435.910(h), and replace them with the following:

Michigan provided this new suggested text: A Social Security Number should be provided for all individuals applying, if the individual has one. If the individual does not have a Social Security Number, leave this box blank. If you need help applying for a Social Security Number call us at 855-276- 4627.

16 The state will remove instructions indicating that benefits may be reduced or denied to otherwise eligible individuals if a Social Security Number is not provided, and replace them with the following:

Michigan provided this new suggested text: A Social Security Number should be provided for all individuals applying, if the individual has one. If the individual does not have a Social Security Number, leave this box blank. If you need help applying for a Social Security Number call us at 855-276-4627.

17 The application contains an inaccurate definition of qualified non-citizen. The state will revise the definition of qualified non-citizen to be consistent with the online application to include the following: Lawful Permanent Resident (LPR/Green Card holder); Asylee; Refugee; Cuban/Haitian Entrant; Paroled into the U.S. for at least one year; Conditional Entrant Granted before 1980; Amerasians; Battered Spouse, Child and Parent; Iraqi/Afghan Special Immigrants ; Victim of Trafficking and his/her Spouse, Child, Sibling or Parent; Granted Withholding of Deportation or Withholding of Removal

18 The state will confirm if it will make changes to the application to include instructions explaining which

immigration statuses are considered lawfully present for the FFE, or if it will revise the language in the instructions that limit eligible statuses to “qualified non-citizen” immigration statuses. A complete list of immigration statuses considered to be lawfully present, are found here: https://www.healthcare.gov/immigrants/immigration-status/

19 The state has confirmed it has changed the application to mark as “optional” the questions asking if an individual is a victim of domestic violence. (Please provide date change was implemented, and documentation verifying this change.)

20 The state will remove questions asking if an individual is a Victim of Trafficking, a seasonal farmworker, and a migrant farmworker.

January 26, 2019 21 The state has explained the question asking whether an individual is a refugee/asylee on the Special Circumstances page is asked of anyone in the household, including applicants and non-applicant household members. Because applicants have an opportunity to indicate asylee/refugee status in the immigration eligibility section, the state will remove the question since it is not needed for eligibility or administration of the state plan, and individuals not seeking coverage for themselves who are included in an applicant’s or beneficiary’s household to determine eligibility of such applicant or beneficiary may not be required to provide information about their citizenship, nationality or immigration status.

Please submit the revised Michigan Bridges alternative online, and MDHHS paper applications to CMS for review upon completion of each change identified above. We continue to be available to provide technical assistance. If you have any questions about your applications, please contact Keri Toback at (312) 353-1754 or Keri.Toback@cms.hhs.gov.

Sincerely,

/s/

Ruth A. Hughes

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Cc: Erin Black Jaqueline Coleman

State/Territory name: Michigan Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. MI-16-0110 Proposed Effective Date 03/01/0016 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435, Subpart J and M Federal Budget Impact Federal Fiscal Year Amount First Year 2016 $0.00 Second Year 2017 $0.00 Subject of Amendment Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Chris Priest, Director Medical Services Administration Updates the application the State will use for individuals who apply for coverage that may be eligible based on the MAGI standard. TN No.: MI 16-0110 Michigan Approval Date: January 11, 2019 Effective Date: March 1, 2016

Submitted By: Erin Black Last Revision Date: Mar 31, 2016 Submit Date: Jan 10, 2019 Signature of State Agency Official TN No.: MI 16-0110 Michigan Approval Date: January 11, 2019 Effective Date: March 1, 2016

State/Territory name: Michigan Transmittal Number: MI-16-0110 Transmittal Number: MI-16-0110 State/Territory name: Michigan Medicaid State Plan Eligibility Medicaid State Plan Eligibility: General Information General Information: Submission Title: short (under 100 characters) label used to identify this submission in the web application Eligibility Process (MI 16-0110) PDFs superseded by this SPA (Include Transmittal Number): Description: Medicaid State Plan Eligibility: File Management Summary Type of SPA Form Code Form Name/Description Uploaded? MAGI-Based Eligibility Groups S14 AFDC Income Standard no MAGI-Based Eligibility Groups S25 Mandatory: Parents and Other Caretakers no MAGI-Based Eligibility Groups S28 Mandatory: Pregnant Women no MAGI-Based Eligibility Groups S30 Mandatory: Infants and Children Under Age 19 no MAGI-Based Eligibility Groups S32 Mandatory: Individuals Below 133% of the FPL no MAGI-Based Eligibility Groups S33 Mandatory: Former Foster Care Children up to age 26 no Single streamlined application or alternative, renewals, coordinatoin for enrollment and eligibility. TN No.: MI 16-0110 Michigan Approval Date: January 11, 2019 Effective Date: March 1, 2016

Type of SPA Form Code Form Name/Description Uploaded? MAGI-Based Eligibility Groups S50 Optional: Individuals Above 133% of the FPL no MAGI-Based Eligibility Groups S51 Optional: Optional Parents and Caretakers no MAGI-Based Eligibility Groups S52 Optional: Reasonable Classifications of Individuals no MAGI-Based Eligibility Groups S53 Optional: Non IV-E Adoption Assistance no MAGI-Based Eligibility Groups S54 Optional: Optional Targeted Low Income Children no MAGI-Based Eligibility Groups S55 Optional: Tuberculosis no MAGI-Based Eligibility Groups S57 Optional: Foster Care Adolescents - Chafee no MAGI-Based Eligibility Groups S59 Optional: Family Planning no Eligibility Process S94 Single streamlined application or alternative, Renewals, Coordination for enrollment and eligibility (agreements with Exchanges) yes MAGI Income Methodology S10 Designates the income options the state is electing in 2014 (e.g. how pregnant women are counted, reasonably predictable changes in income, cash support, how full-time students are counted) no Single State Agency A1-3 Addresses single state agencies delegation of appeals and determinations no Residency S88 State affirms residency regulations and addresses interstate agreements and temporary absence no Citizenship & Immigration Status S89 State affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility no Hospital Presumptive Eligibility S21 State specifies options for presumptive eligibility conducted by hospitals no Marriage Policy S12 Medicaid Eligibility Marriage Policy no Medicaid State Plan Eligibility: File Management Detail Form S14: AFDC Income Standards TN No.: MI 16-0110 Michigan Approval Date: January 11, 2019 Effective Date: March 1, 2016

Form Description: Uploaded Form: Date Uploaded: Form Description: Uploaded Form: Date Uploaded: Form Description: Uploaded Form: Date Uploaded: Support Documents Document Form S25: Eligibility Groups - Mandatory Coverage: Parents and Other Caretaker Relatives Support Documents Document Form S28: Eligibility Groups - Mandatory Coverage: Pregnant Women Support Documents Document Form S30: Eligibility Groups - Mandatory Coverage: Infants and Children under Age 19 TN No.: MI 16-0110 Michigan Approval Date: January 11, 2019 Effective Date: March 1, 2016

Form Description: Uploaded Form: Date Uploaded: Form Description: Uploaded Form: Date Uploaded: Form Description: Uploaded Form: Date Uploaded: Support Documents Document Form S32: Eligibility Groups - Mandatory Coverage: Adult Group Support Documents Document Form S33: Eligibility Groups - Mandatory Coverage: Former Foster Care Children Support Documents Document Form S50: Eligibility Groups - Options for Coverage: Individuals above 133% FPL TN No.: MI 16-0110 Michigan Approval Date: January 11, 2019 Effective Date: March 1, 2016

Form Description: Uploaded Form: Date Uploaded: Form Description: Uploaded Form: Date Uploaded: Form Description: Uploaded Form: Date Uploaded: Support Documents Document Form S51: Eligibility Groups - Options for Coverage: Optional Coverage of Parents and Other Caretaker Relatives Support Documents Document Form S52: Eligibility Groups - Options for Coverage: Reasonable Classification of Individuals under Age 21 Support Documents Document Form S53: Eligibility Groups - Options for Coverage: Children with Non IV-E Adoption Assistance TN No.: MI 16-0110 Michigan Approval Date: January 11, 2019 Effective Date: March 1, 2016

Form Description: Uploaded Form: Date Uploaded: Form Description: Uploaded Form: Date Uploaded: Form Description: Uploaded Form: Date Uploaded: Support Documents Document Form S54: Eligibility Groups - Options for Coverage: Optional Targeted Low Income Children Support Documents Document Form S55: Eligibility Groups - Options for Coverage: Individuals with Tuberculosis Support Documents Document Form S57: Eligibility Groups - Options for Coverage: Independent Foster Care Adolescents TN No.: MI 16-0110 Michigan Approval Date: January 11, 2019 Effective Date: March 1, 2016

Form Description: Uploaded Form: Date Uploaded: Form Description: Uploaded Form: Date Uploaded: Form Description: S94 - General Eligibility Requirements, Eligibility Process Uploaded Form: Date Uploaded: 10/20/2013 S94 - Eligibility Process FINAL (2-5-14).pdf Support Documents Document Form S59: Eligibility Groups - Options for Coverage: Individuals Eligible for Family Planning Services Support Documents Document Form S94: General Eligibility Requirements: Eligibility Process Support Documents Document TN No.: MI 16-0110 Michigan Approval Date: January 11, 2019 Effective Date: March 1, 2016

Document Please provide a short description of this support document: Uploaded Document Name: Date Uploaded: 01/10/2019 MDHHS-1171-Paper Multi-benefit Application 10-18.pdf Please provide a short description of this support document: Uploaded Document Name: Date Uploaded: 01/10/2019 MI Bridges Healthcare Only App 1.26.19 Release Part 2 of 2.pdf Please provide a short description of this support document: Uploaded Document Name: Date Uploaded: 01/10/2019 MI Bridges Healthcare Only App 1.26.19 Release Part 1 of 2.pdf Please provide a short description of this support document: CMS created document - Coordination placeholder Uploaded Document Name: Date Uploaded: 01/29/2014 MI 13-0140 MM2 Coordination Placeholder revised (2-4-14).doc Please provide a short description of this support document: CMS created document - Superseding pages Uploaded Document Name: Date Uploaded: 01/29/2014 Michigan 13-0140-MM2 Superseding Pages Document (1-27-14).doc Michigan's paper multi-benefit application. This includes screen shots of the application related to adding Medicaid coverage above 133% up to 400% FPL for children under 21 and pregnant women. This coverage is to further the Flint, Michigan Michigan's online multi-benefit application Part 2 of 2. This includes screen shots of the application related to adding Medicaid coverage above 133% up to 400% FPL for children under 21 and pregnant women. This coverage is to further the Michigan's online multi-benefit application Part 1 of 2. This includes screen shots of the application related to adding Medicaid coverage above 133% up to 400% FPL for children under 21 and pregnant women. This coverage is to further the TN No.: MI 16-0110 Michigan Approval Date: January 11, 2019 Effective Date: March 1, 2016

Form Description: Uploaded Form: Date Uploaded: Form Description: Uploaded Form: Date Uploaded: Document Please provide a short description of this support document: Michigan's Application for Health Coverage - DCH-1426 Uploaded Document Name: Date Uploaded: 01/09/2019 DCH-1426-Expansion-Application and Appendix A-B-C-D-10-2018.pdf Form S10: MAGI-Based Income Methodologies Support Documents Document Form A1-3: Medicaid Administration: Single State Agency Support Documents Document Form S88: Non-Financial Eligibility: State Residency TN No.: MI 16-0110 Michigan Approval Date: January 11, 2019 Effective Date: March 1, 2016