State Child Health Plan Under Title XXI of the Social Security Act

State Children’s Health Insurance Program State of Minnesota

State Child Health Plan Under Title XXI of the Social Security Act State Children’s Health Insurance Program

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

State: MINNESOTA (Name of State/Territory)

As a condition of receipt of Federal funds under Title XXI of the Social Security Act,

(Signature of Governor of State/Territory, Date Signed)

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

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing date resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HCFA, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management, and Budget, Washington, D.C. 20503.

Section 1. General Description and Purpose of the State Child Heath Plans (Section 2101)

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

1.1

Obtaining coverage that meets the requirements for a State Child Health Insurance Plan (Section 2103); OR

1.2 X Providing expanded benefits under the State’s Medicaid plan and the State’s 1115 waiver, Minnesota Health Care Reform Waiver ; OR

1.3

A combination of both of the above.

INTRODUCTION

Minnesota’s Medicaid State plan in effect on April 1, 1997 provides for coverage of infants up to age one with family income equal to or less than 275% of the federal poverty level; and Minnesota received approval under an 1115 waiver on April 27, 1995 to cover children up to age two with income equal to or less than 275% of poverty. Minnesota proposes a Medicaid expansion to provide Medicaid to children under age two in families with income above 275%, but no more than 280% of the federal poverty level.

This small expansion for infants under age two in families with income over 275% up to 280% of federal poverty will not result in “crowd-out,” meaning erosion of the rate of private insurance for Minnesota residents, for a number of reasons.

1990 Census data indicate that Minnesota had approximately 1,500 children residing in the state with income in that narrow 5% range. This is approximately 0.03% of Minnesota's total population. Even if all 1,500 children lost or dropped insurance coverage due to the proposed Medicaid expansion, the effect on the private market of such a small population exiting is inconsequential.

It is virtually impossible for insurers to “carve out” this group of children, for both legal and practical reasons. There are a number of state statutes prohibiting this type of discrimination in the insurance industry, and one law that specifically prohibits insurers from using eligibility for Medicaid as an underwriting factor or reason to deny coverage.1

1 Minn. Stat. §62A.045 prohibits discrimination based on eligibility for public assistance. Minn. Stat. §72A.20, subd. 9 would make this type of carve out illegal as a prohibited trade practice. Minn. Stat.

It would not be practical for employers or insurers would want to exclude these children, since they would have to somehow means test applicants/employees, and completely alter their premium structure. Given that there are only 1,500 children total, this type of exclusion would more likely produce additional expense for employers/insurers.

While it is theoretically possible for families within that 5% range to drop coverage for their children under age two in order to qualify for Medicaid, we view that as unlikely. For many families, there would be no financial advantage in doing so, since premiums for dependents tend to be fixed after the second or third child. Families that dropped coverage would then be faced with attempting to obtain private coverage after the child reaches age two. Fear of being unable to find affordable coverage is a significant deterrent to dropping coverage in the first place.

Finally, the MinnesotaCare Program has been in existence for five years, and has been shown not to have any significant negative effect on the rate of insurance in Minnesota.

The Title XIX State plan amendments for the Medicaid expansion are included as Attachment I.

As directed by our Legislature, Minnesota will shortly submit a request for 1115 waivers to allow the State to incorporate its MinnesotaCare program as a Child Health Insurance initiative under Title XXI.

Minnesota will also submit separately a Child Health Insurance plan amendment outlining a program to provide a subsidy enabling families to utilize employer-sponsored insurance for currently uninsured children. Children with access to health insurance which is subsidized by a parent’s employer are not eligible for the MinnesotaCare program. Health insurance from the employer is considered subsidized if the employer contributes at least 50% of the cost of coverage. Despite the contribution by the employer, the employee share of dependent coverage is not affordable to many low-income families. Minnesota will propose a Child Health Insurance Program that subsidizes health insurance available from an employer for children not eligible for MinnesotaCare.

§62A.65 prohibits the use of exclusionary riders, with certain exceptions which are not applicable to this example.

Section 2. General Background and Description of State Approach to Child Health Coverage (Section 2102(a)(1)-(3)) and (Section 2103(c)(7)(A)-(B))

2.1 Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in section 2110(c)(2)). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships.

OVERVIEW OF HEALTH COVERAGE IN MINNESOTA

Historically, Minnesota has had one of the lowest rates of uninsurance in the country. Of the 4,649,596 individuals in Minnesota in 19962, approximately 6 percent to 9 percent, or between 280,000 and 420,000, lacked health coverage at any point in time during the year.3 While estimates of uninsurance in Minnesota vary by source, all surveys indicate that Minnesota’s rate of uninsurance has remained stable over the course of the 1990s, in contrast to the experience nationally, where the numbers of uninsured have continued to climb.4

Sources of Health Insurance Coverage for Minnesotans

Data from the Minnesota Department of Health shows the distribution of Minnesota’s population by primary source of health insurance coverage.5 In 1996, two-thirds (67%) of Minnesotans received their primary health insurance coverage through a private sector source, either from an employer or individually purchased. Public program enrollment, including Medicare, accounted for approximately 25 percent of Minnesotans, and estimates of the uninsured ranged from 6 percent to 9 percent.

2 U.S. Bureau of the Census, Estimates of the Population of State: Annual Time Series, July 1, 1990 to July 1, 1997, press release of December 31, 1997. 3 Estimates of the uninsured in Minnesota differ by the source of the estimates. Surveys conducted by the University of Minnesota in 1990 and 1995 show the rate of point-in-time uninsurance to be 6.0 percent, while the Current Population Survey (using three-year average data) shows the rate to be approximately 9.2 percent. 4 The Current Population Survey (CPS) indicates that rates of uninsurance nationally have risen from 13.6 percent in 1990 (three-year average rate) to 15.4 percent in 1996. CPS data shows Minnesota’s rate of uninsurance to be stable over this same time period at approximately 9.2 percent. 5 Some individuals are enrolled in more than one type of health insurance coverage. For example, many Medicare enrollees also are enrolled in Minnesota’s Medical Assistance program. The information presented in Table 1 counts individuals only once, however, and assigns them to coverage based on the primary payer for coverage.

Table 1: Primary Source of Health Insurance Coverage for Minnesotans, 1996

Source Percent Covered Employer-Based 62%-65% Individual 5% Medical Assistance 8% MinnesotaCare 2% Medicare 14% Other Public 1% Uninsured 6%-9%

Note: Numbers may not total to 100% due to rounding. Source: Minnesota Department of Health.

Excluding Minnesota’s elderly, nearly all of whom have Medicare as their primary source of insurance coverage, shows that approximately three-quarters (76%-79%) of non-elderly Minnesotans receive health coverage through a private sector source, with 15% receiving coverage through a public program (either Medical Assistance, MinnesotaCare, Medicare, or another public program). Between 7 percent and 10 percent of non-elderly Minnesotans are uninsured at any point in time.

Trends in Uninsured Minnesotans

Minnesota has traditionally had one of the nation’s lowest rates of uninsurance. While estimates of the rate of uninsurance for Minnesota vary based on the source of the estimate, all sources agree that Minnesota’s rate of uninsurance has remained stable while the nation’s overall rate has increased. Table 2 shows three-year average uninsurance rates for Minnesota and the U.S.

Table 2 Three Year Average Rates Percent of Population Lacking Health Insurance Coverage Minnesota and U.S.

Average Ending

Minnesota

U.S. 1990 8.7% 13.6% 1991 8.9 13.9 1992 8.8 14.2 1993 9.2 14.7 1994 9.2 15.1 1995 9.2 15.3 1996 9.2 15.4

Source: U.S. Bureau of the Census, Current Population Survey.

In aggregate, depending on the estimate used, 280,000 to 420,000 Minnesotans lack health insurance coverage at any given time, a rate that has been stable over the 1990s. Table 3 (on the following page) shows additional detail on how the uninsured in Minnesota are distributed among various demographic and income groups.

There have been several notable shifts in the uninsured population between 1990 and 1995. In particular, the representation of lower income populations and children among the uninsured has fallen considerably since 1990. In 1990, nearly two-thirds of the state’s uninsured had incomes below 200% of the federal poverty guidelines and one-quarter of the state’s uninsured were children. As a result, the MinnesotaCare program was designed to focus on these populations: children and the working poor who may not have access to Medical Assistance. Therefore, while eligibility for MinnesotaCare extends up to 275 percent of the federal poverty level, 91 percent of the enrollment in the program is for individuals with incomes of 200 percent or lower of the federal poverty level. The effect of MinnesotaCare’s focus on lower-income individuals is evident. By 1995, the percentage of the uninsured who had incomes below 200 percent of poverty had declined to approximately 40 percent. It is likely that the focus of the MinnesotaCare program on lower income individuals had a significant impact on reducing uninsurance among this group.

TABLE 3: Who are the uninsured in Minnesota? 1990 and 1995

1990 1995 Gender

Male

Female

50.0% 50.0%

55.0% 45.0%

Employment Status (adults)

Self-employed

Employed by someone else

Homemaker

Unemployed

Retired

22.5% 46.7% N/A 18.8% 2.9%

23.9% 58.1% 4.4% 11.7% 2.1% Marital Status (adults)

Single

Married

Living with partner

Divorced/widowed/separated

42.0% 42.2% N/A 15.9%

43.4% 37.1% 12.0% 7.9% Race/Ethnicity

White

African American

American Indian/Alaskan Asian/Hmong/Pacific Islander

Hispanic/Latino

Other

94.0% 3.2% 0.2% 0.7% 1.4% 0.6%

86.6% 2.9% 2.2% 1.4% 3.6% 3.4% Education Level (adults)

Less than high school

High school degree

Some college/tech school

College graduate/Grad School/Beyond

9.1% 38.9% 40.3% 11.6%

10.5% 36.6% 37.1% 17.0% Region of state (by Regional Coordinating Board region)

RCB 1 (Northwest MN)

RCB 2 (Northeast MN)

RCB 3 (Central MN)

RCB 4 (seven-county metro)

RCB 5 (Southwest MN)

RCB 6 (Southeast MN)

8.2% 12.3% 14.5% 46.5% 10.4% 8.1%

5.4% 8.8% 13.3% 53.4% 9.6% 9.5% Income (as % of federal poverty guidelines)

0%-100%

101%-200%

201%-300%

301%-400%

401% +

16.8% 41.7% 24.1% 9.2% 8.2%

12.6% 33.1% 25.7% 13.6% 14.9%

Source: Minnesota Health Care Access Commission Household Survey, 1990 and University of Minnesota Health Insurance and Access Survey, 1995. Uninsured defined as point-in-time.

Uninsured Children

Minnesota has traditionally had one of the nation’s lowest rates of uninsured children. Estimates of the rate of uninsurance among children in Minnesota range from 4.3% to 7.2% (or 52,000 to 89,000

children).6 For the purposes of the S-CHIP program, targeted low-income children are defined as those children (under age 19) below 200% of poverty. In 1996, Minnesota had approximately 1,377,190 children under the age of 19.7 Of this group, 31.5%, or approximately 405,000 children were in families with incomes at or below 200% of the federal poverty level.8 Of these low-income, uninsured children, an estimated 50,000 lack health insurance coverage.9

Minnesota has made great strides to reduce the rate of uninsurance among children. It is likely that the cumulative effect of a number of insurance reforms instituted in the early 1990s combined with a strong economy has had an impact on reducing uninsurance among children. Insurance market reforms included limitations on underwriting and rating differentials in the small group market (including guaranteed issue, guaranteed renewal, and rate bands) and individual health insurance markets (where guaranteed renewal and rate regulations were instituted), and the establishment of the MinnesotaCare Program.

Between 1990 and 1995, the percentage of children who lack health insurance coverage for 12 months or more (long-term uninsured children) fell dramatically, from 5.2% of the state’s children to 3.1%.10 The combination of the health insurance reforms and a strong business climate led to a dramatic increase in offering of health insurance by small employers in Minnesota, and a subsequent increase in the number of individuals enrolled in small group plans.11 It is likely that some previously long-term uninsured children became insured through new small group plans. The establishment of the MinnesotaCare Program also likely had a large impact on reducing overall long-term uninsurance rates among Minnesota’s children. Approximately 50,000 Minnesota children are currently enrolled in MinnesotaCare.

However, while long-term uninsurance has been reduced considerably, the percentage of children who are uninsured for part of the year has not been reduced but has remained stable at approximately 5.8% of the state’s children.12 So, although the MinnesotaCare

6 The 4.3% figure is the point-in-time estimate of uninsured children under the age of 19 from the University of Minnesota Health Insurance and Access Survey, 1995. The 7.2% estimate is derived using a three-year moving average of uninsurance rates from the Current Population Survey for 1994 through 1996 for children under age 18. 7 U.S. Bureau of the Census, Current Population Survey, 1997. 8 Based on a three-year moving average of CPS data. 9 U.S. Census Bureau web site, table of Low Income Uninsured Children by State, 3-year average of the CPS for 1993-1995. 10 Call, K.T., et al. “Who Is Still Uninsured in Minnesota? Lessons From State Reform Efforts,” Journal of the American Medical Association, October 8, 1997, Vol. 278, No. 14. 11 Enrollment in small group (2-50 employees) products in Minnesota’s health insurance market increased from slightly less than 300,000 in 1994 to over 400,000 by 1996. 12 Call, K.T., et al. “Who Is Still Uninsured in Minnesota? Lessons From State Reform Efforts,” Journal of the American Medical Association, October 8, 1997, Vol. 278, No. 14.

program has been successful in reducing long-term rates of uninsurance, survey results show that up to 85% of those children who are uninsured are likely to be eligible to qualify for the MinnesotaCare program. Therefore, there appears

to be a substantial population yet to reach among Minnesota’s children.13

Uninsured by Race/Ethnicity

The Robert Wood Johnson Foundation (RWJF) Survey, conducted in 1993, found a higher rate of uninsurance among minority groups, however the sample size was not large enough to be statistically significant. The 1995 Minnesota Health Insurance Access Survey conducted by the University of Minnesota, (which estimated an overall rate of uninsurance in Minnesota at 6%), substantiated the RWJF findings.

The portion of the uninsured population which is made up of minority groups in Minnesota has increased for every sub-group except African Americans. And the rate at which minority populations are represented in the uninsured ranks is in all cases higher than the overall portion of the population they represent in the state.14 Unfortunately, this information is not available specifically for minority children in Minnesota. Table 4 recaps the rate of uninsured by race in 1990 and 1995, compared to the State population by race in 1990:

Table 4: Minnesotans Uninsured by Race/Ethnicity, 1990 and 1995 Race 1990 1995 % of the Overall MN Population, 1990 White 94.0% 86.6% 92.28% African American 3.2% 2.9% 2.8% American Indian/Alaskan 0.2% 2.2% 1.2% Asian/Hmong/Pacific Islander 0.7% 1.4% 2.3% Hispanic/Latino 1.4% 3.6% 1.6% Other 0.6% 3.4% n/a

Source: Minnesota Health Care Access Commission Household Survey, 1990 and University of Minnesota Health Insurance and Access Survey, 1995 (Uninsured defined as point-in-time); U.S. Census Bureau and Minnesota State Demographer’s Office.

STATE-SUBSIDIZED HEALTH COVERAGE

Health Care Programs of the Department of Human Services Minnesota currently provides coverage of health care services for about 525,000 low- income, uninsured individuals, some with special health care needs. This population is served through three programs administered by the Minnesota Department of Human

13 Estimate from the Minnesota Department of Human Services, based on information contained in the 1995 Minnesota Health Insurance and Access Survey, conducted by the University of Minnesota. 14 Comparison of data from the Minnesota Health Care Access Commission Household Survey, 1990 and the University of Minnesota Health Insurance and Access Survey, 1995, for uninsured rates at a point in time.

Services: Medical Assistance, MinnesotaCare and the General Assistance Medical Care Program. Approximately 300,000 of all enrollees are children.

Table 5 Minnesotas in Public Health Care Programs, September 1997

Medicaid MinnesotaCare GAMC Total in Program 392,681 99,824 33,118 Children < 21 223,204 53,511 1,345 Children < 19, and under 200% of FPL 212,544 43,769 1,293

Medical Assistance The Minnesota Medical Assistance program covered around 400,000 individuals at any point in time during 1997, and approximately 220,000 of these were children under the age of 21. Minnesota Medical Assistance provides coverage for acute, chronic and long- term care needs. Approximately 160,000 recipients receive services through a managed care delivery system. The program also provides medical services through a number of waiver projects which include home and community-based service waivers for persons with mental retardation and related conditions, and for the disabled, elderly and chronically ill individuals.

Table 6 Children in Medicaid Program by Age and Race, September 1997 Race 0 - 1 years 2 - 5 years 6 - 18 years 19, 20 years Total < Age 19 Total < Age 21 African American 6,473 11,953 25,711 1,892 44,137 46,029 Asian 2,819 5,241 14,064 674 22,124 27,298 Hispanic 3,817 4,202 7,052 678 13,303 15,749 American Indian 1,883 3,123 9,076 604 14,082 14,686 White 24,480 28,479 83,400 6,772 116,359 123,081 Unknown 269 114 388 90 771 861 All 39,741 53,112 119,691 10,660 212,544 223,204 Minnesota Medical Assistance covers pregnant women and infants from birth to age 2 with income at or below 275% of the federal poverty level of income; children age 2 through 5 at or below 133% of federal poverty, and children age 6 through 15 at or below 100% of federal poverty. The Program covers medically needy families and other families whose eligibility is related to AFDC with income no more than 133 and 1/3% of

the AFDC standard. Children above age 15 to age 21 are covered as medically needy. No asset test applies to children.15

MinnesotaCare The MinnesotaCare program began in 1987 with the Children’s Health Plan, a state- funded effort to address the rising numbers of uninsured children. In 1992, the program was expanded to include families and to provide coverage with premium cost-sharing on a sliding scale basis. At that time, children under age 18 and families with income up to 185% of the federal poverty level were eligible. The service package contained service limitations, most notably a limitation on hospitalization costs. No asset limit has been applied to eligibility. However, in 1997 the State Legislature adopted asset limits of $15,000 for one, and $30,000 for two or more, but exempting pregnant women from any asset requirement. This change has not been implemented in the MinnesotaCare Program.

Expansion under 1115 waiver In 1995, Minnesota received approval under its Health Care Reform Waiver to obtain Medicaid matching funds through MinnesotaCare for pregnant women and children up to age 21 in families with income up to 275% of federal poverty. All children and pregnant women began receiving the full Medicaid benefit set of services under this waiver. Service delivery in MinnesotaCare was also converted to managed care by the end of 1996.

The MinnesotaCare Program is 100% state-funded for coverage of parents, legal guardians of minor children, dependent siblings up to age 25 in eligible families. Coverage is available to these other family members with household income up to 275% of federal poverty levels. Adults without children are eligible if household income at or below 175% of the federal poverty level.

The MinnesotaCare program has an approximate monthly enrollment of 100,000 individuals. More than half of the enrollees are children under age 21. A significant portion, or 71%, of the children enrolled are in families with income below 150% of the federal poverty level.

Table 7 Children in MinnesotaCare Program, by Age, Race and Income Level, September, 1997

15 The asset test which became applicable to families and children on 7/1/97 was repealed by the 1998 Legislature, unless the state receives federal approval to maintain the asset test under an 1115 waiver.

Race 0 - 1 years 2 - 5 years 6 - 18 years 19, 20 years Total < Age 19 Total < Age 21 African American 51 356 1,527 133 1,934 2,067 Asian 74 395 1,496 151 1,965 2,116 Hispanic 26 162 687 67 875 942 American Indian 4 42 291 20 337 357 White 696 6,713 28,394 2,738 35,803 38,541 Unknown 1,639 460 6,578 811 8,677 861 Total 2,490 8,128 38,973 3,920 49,591 53,511

Income Level Children < Age 21 0 - 100% 101 - 150% 151 - 200% 201 - 250% 251 - 275% 275 + % 53,511 14, 495 21, 040 11,775 4,352 819 1,030

Private Insurance Protections To deter employer shifting of health coverage to the public sector, insurance barriers were adopted in MinnesotaCare. Families were not eligible to enroll for 18 months after the loss of employer subsidized health coverage, and were required to wait 4 months after the loss of any other type of health coverage. Families with employer-subsidized insurance available to them are not eligible for MinnesotaCare.

To assure health care to children in families with incomes at or below 150% of the federal poverty level, two enrollment conditions are waived for this group of children: (i) The 4-month waiting period after termination of other health coverage does not apply to these children; and (ii) the four-month penalty period for nonpayment of the premium is not imposed on these children. In addition, children under age two are not disenrolled with other family members for nonpayment of premiums.

All MinnesotaCare applicants with income above 200% of federal poverty levels receive information regarding the availability of private insurance provided by the Department of Commerce. Premiums For families with income above 150% of the federal poverty level, premiums are established on a sliding scale from 1.8% to 8.8% of gross income, with premiums set at full cost when income is at or above 275% of the federal poverty level. For children in families with income at or less than 150% of the federal poverty level, the premium is fixed at $4 per month.

Benefit Limits Pregnant women and children in MinnesotaCare receive the full set of benefits allowed under the Minnesota Medical Assistance program. However, benefit limits apply to

adults who are not eligible pregnant women. A ten percent co-payment applies to inpatient hospital costs of adults with gross family income above 175% of the federal poverty level. Adults receive preventive dental services only16, and have limitations on mental health services17.

General Assistance Medical Care (GAMC) The GAMC program is a state-funded program which provides acute and primary health care

16 Non-preventive dental services for adults (with the exception of orthodontia) will be added effective July 1, 1998. 17 Covered outpatient mental health services are the following: diagnostic assessments, psychological testing, explanation of findings, medication management, day treatment, partial hospitalization, and psychotherapy.

coverage for persons who are not eligible for Medical Assistance. Individuals who may be covered include non-citizen children, and persons who are of advanced age or incapacitated, undocumented and nonimmigrant persons. The program serves approximately 33,000 residents, and about 1,300 are children. One third of this population are served through managed care plans. This program offers the same basic health services as Medical Assistance but does not include long term care, home care or personal care services. The program has provided health care coverage since 1973.

Table 8 Children in GAMC by Age, September, 1997 Age 0 - 1 2 - 5 6 - 18 19, 20 Total < 19 Total < 21 Number 27 325 941 52 1,293 1,345

Table 9 Children in GAMC by Race, September 1997 Race African American Asian Hispanic Native American White Unknown Total < 21 Number 77 96 1,100 13 56 3 1,345

Health Services of the Department of Health The Minnesota Department of Health’s Division of Family Health administers, coordinates and supports many activities statewide addressing maternal and child health, including the Title V Block Grant funds for maternal and child health. The Department is also the designated lead agency for health care reform. The responsibilities of the Department of Health are carried out in conjunction with its many activities related to the public health. These include the statewide planning and coordination of maternal and child health services through the acquisition and analysis of population-based health data; the provision of technical support and training; the coordination of various public and private maternal and child health efforts; and support for targeted maternal and child health services in communities with significant populations of high risk, low income families through the grant process.

These program goals are accomplished through both state and local partnerships. The Minnesota Department of Health has interagency agreements with the Department of Human Services to carry out shared responsibilities related to EPSDT requirements, and partnerships with the Department of Children, Families and Learning, and local community health boards. In addition, maternal and child health program efforts involve an extensive system of community health agencies, schools, private non-profit and public agencies, volunteer organizations, hospitals and other health professionals.

Current five-year goals of the Title V Block Grant include reduction in the infant mortality rates of two minority populations - African Americans and American Indians; improvement in the initiation of prenatal care during the first trimester for these two

populations as well as the Asian/Pacific Islander women; and improvement in the adequacy of prenatal care in these groups.

Maternal and Child Health Special Projects: The Maternal and Child Health (MCH) section of the Division of Family Health is responsible for state-administered maternal and child health projects, and oversight of community-based programs. The Minnesota Maternal and Child Health law requires the state to target high-risk and low-income individuals with four specific statewide priorities: family planning, improved pregnancy outcomes, services to children with or at risk for developing a handicapping condition or chronic illness; and childhood injury prevention. Grants funded by Title V along with a state appropriation are distributed on a needs-based formula by Community Health Boards to non-profit organizations, public agencies and American Indian tribes to carry out these objectives. In addition, local programs which began before 1981 are continued through the Special Projects grant system: a comprehensive preventive and primary care service system for Minneapolis children and youth which includes off-site services, school-based services and after-hours emergency care; the Adolescent Health Program for health services and education at five St. Paul school-based sites, a project internationally known as a model for prevention of unplanned adolescent pregnancies and for interagency service integration; and finally a preventive dental health service project for rural elementary school children of the Goodhue-Wabasha Community Health Board.

MCSHN: A major project funded by the Title V Block Grant is the program for Minnesota Children with Special Health Needs (MCSHN) which promotes the development of integrated health services for children with special health needs through a network of agencies at the state, regional and local levels. The program is developing a statewide needs assessment system and enhanced data capacity for the purpose of providing population-based data regarding unmet need which is critical for establishing priorities, services designs and measuring program effectiveness.

Children with chronic illness or conditions which interfere with normal growth are eligible for services from professional staff who work to assure that the child has access to comprehensive and appropriate health services, and provide coverage of necessary services not reimbursable through any other source. Based on conservative estimates, 79,000 children18 in the state potentially qualify as children with special health needs. MCSHN participates in a number of interagency projects which include the Early Childhood Intervention Project; the Family Support and Preservation Project; Family Services and Children’s Mental Health collaborative; adolescent transition projects and grants; child find projects; and numerous health care reform activities. In 1996, approximately 5,600 children received direct services such as clinic assessments, treatment, evaluations and early intervention services. The program sponsors a service to track about 1,700 children from birth to age 4 considered “at risk”.

18 With a broader definition of this group, as children with chronic health conditions who require more than routine health care, this group would be approximately 431,000, or 30% of the child population.

Targeted Services: A number of Family Health Division projects target specific services or populations:

Fetal Alcohol Syndrome - a new initiative to prevent and reduce harm from FAS/FAE

Healthy Beginnings Program - a universally offered home visiting program responding to all live births in certain geographic areas, to promote positive parenting and healthy child development.

Minnesota Education Now and Babies Later - a multi-faceted, primary prevention, community health promotion approach to the reduction of adolescent pregnancies, targeting 12 to 14 year olds, their parents, schools and communities.

Tobacco-Free Communities for Children - a multi-faceted approach to reduce the number of children who use tobacco.

WIC Outreach - additional state funds will be used to inform potential recipients of the necessity of good nutrition and availability of the WIC program.

Newborn Metabolic Screening Intiative - provides testing, follow-up and support to families with a newborn testing positive for a metabolic disorder.

Targeted Home Visiting Programs - Nine grants are issued to provide for early intervention in the form of home visiting services to families at risk of child maltreatment.

Newborn Hearing Screening - a new initiative which will assist hospitals and other health care facilities to screen infants for hearing loss, and promote hearing loss screening of infants statewide.

SSI Safety Net - a project to reduce the gaps in medical service needs of children who lose SSI as a result of the more restrictive citizenship requirements or the child disability requirements (although Medicaid has now been restored to children losing SSI due to changes in the definition of child disability).

Nutrition Programs: The Supplemental Nutrition Program in the Division of Family Health, Department of Health is responsible for the federal nutrition programs, Women Infants and Children (WIC) and the Commodity Supplemental Food Program for Mothers (MAC). These programs are administered through various local agencies: public health agencies, community action agencies, tribal governments, and migrant health facilities. In addition, the Supplemental Nutrition Program has a cooperative agreement with the Minnesota Department of Agriculture for the issuance of food coupons to WIC recipients during the summer months for the purchase of fresh fruits and vegetables at farmer’s markets. This program operates in 15 to 18 counties with members in the Minnesota Growers Association.

Community Health Services: Considerable responsibility for public health efforts, and maternal and child health efforts rests with the local public health infrastructure, a network of 50 Community Health Boards, established under the Community Health Services Act of 1976. Of these, 65 operate as cooperative, multi-county boards. The Community Health Board system was a strategic step toward establishing a partnership approach to meeting public health needs in the state. The roles of both state and local agencies was further refined by the Local Public Health Act of 1987.

Many public health service, agencies under the auspices of the Community Health Boards carry out functions important for the health of children. Local public health agencies are clinic providers of the EPSDT program. In addition, local public health agencies provide school health services through contracts or cooperative arrangements with school districts. In addition, the state and local partnership of public health agencies are engaged in a number of projects to redesign community-based services to better serve the needs of children. These initiatives include the Children’s Mental Health Collaborative, the Family and Community Services Collaboratives, and Part H Collaboratives, all of which mandate interagency program planning, service coordination, and blended funding. Title V programs are also significantly involved in these initiatives.

PUBLIC-PRIVATE PARTNERSHIPS

Minnesota Comprehensive Health Act The Minnesota Comprehensive Health Association (MCHA) health plan is a private- public partnership. MCHA is a non-profit, Minnesota corporation established by the Minnesota Legislature in 1976 to assure the availability of health care benefits to all qualified Minnesota residents who have been turned down by Minnesota’s private market for individual health insurance. The program became operational in 1977, and is by far the largest high risk pool in the nation.

The costs of the program are funded by assessments against all health and accident insurance companies in the state, premiums charged to subscribers, and state appropriations. Because it costs more to provide health care to enrollees with poor health status, premiums are higher than those charged by commercial insurers, but are capped in an effort to contain the cost to the enrollee.

The total number of individuals enrolled during 1997 ranged from 27,000 to 30,000. There were 1,804 children served by this program in calendar year 1997. Most (1,278) were dependents of eligible parent subscribers, but 526 children covered as individual policy holders. The state’s insurance reforms in 1992 have contributed to a decline in the enrollment of MCHA; these reforms included a guaranteed issue small group product, prohibiting riders in individual policies, and carving out high-risk groups, a mandatory ceiling on conversion policies, small-group reform measures, relaxing standards in commercial market underwriting, and an improved economy.

Migrant Health Service, Inc. (MHSI) Migrant Health Services, Inc. is a non-profit organization which was formed to make health care accessible to farm workers who travel to work in the fields of Minnesota and North Dakota. The organization has provided and promoted comprehensive health care for farm worker families for 25 years. Ninety-eight percent of the population served is without health insurance. The program is funded with approximately 80% federal and state grants; and approximately 20% private foundation grants and patient fees. Currently, MHSI operates 10 health centers as well as a mobile health unit, providing extended service hours, for 10 to 20 weeks of the summer.

The health centers are staffed with nurses, bilingual outreach staff and clerks, and nutritionists. Services provided health education, care and education of pregnant and diabetic patients, limited vouchers for medical treatment, treatment referrals and home visits. Contracts are made with local providers to provide extended hours. Through a cooperative effort with the University of Minnesota Dental School, dental screening and dental services are provided to children who are enrolled in migrant school programs in the southern part of the State.

Headstart programs for children of farm workers are operated at 14 sites in Minnesota each summer by the Tri-Valley Opportunity Council, Inc., a community action agency

(CAP). These programs offer EPSDT services to enrolled children, in coordination with the health programs of MHSI.

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

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e. Medicaid and state-only child health insurance): Medical Assistance In Minnesota, the Department of Human Services supervises, and counties administer the Medical Assistance program through the local offices of 87 county agencies which make available basic program information in written material, and respond to inquiries made by phone or in person. Metropolitan counties and counties with large geographic areas may have multiple office locations. In major metropolitan areas (Minneapolis., St. Paul, Duluth) staff are outstationed in hospitals and other community-based settings (these include public health offices, social service agencies, and medical providers).

Applicants have the option of mailing in application forms. One application form is used for all Minnesota health care programs.19 A toll free phone line is available for health care program inquiries. In addition, callers on the toll-free lines to MinnesotaCare Minnesota Children with Special Health Needs are screened for potential Medical Assistance eligibility.

Eligibility for Medical Assistance is coordinated with MinnesotaCare, by screening MinnesotaCare applicants for potential Medical Assistance eligibility. Pregnant women and children who may be eligible for Medical Assistance (and thus be relieved of premium obligations) are advised of their potential eligibility and given the option of changing programs.

MinnesotaCare Eligibility determinations in the MinnesotaCare Program are made by Minnesota Department of Human Services staff. Application procedures include mailing of application forms, and the use of more convenient methods of financial verification. A toll free number is available for program inquiries and eligibility questions. A period of 30 days applies to application processing; however, if the applicant is a pregnant women, the processing period is 10 days. Eligibility renewal is required annually and is also conducted by mail.

Application forms are made available at various community sites which forward them to the State agency: provider offices; school districts, public and private elementary schools, community health offices, WIC program sites, and local human services agencies. A

19 However, applicants for cash assistance are not required to complete the separate Health Care Program Application, in order to have eligibility for health care programs determined. All necessary eligibility information is contained in the form used by the cash programs.

MinnesotaCare Benefits handbook outlines program coverage and eligibility requirements.

Outreach efforts in MinnesotaCare during the first 4 years were designed to reach a statewide population in the form of media campaigns, printed information placed in community-based agencies, and mass mailing campaigns with health associations and state tax forms. More recently, efforts have been designed to target specific populations which include ethnic and racial minority communities, employers not offering health care coverage, public health agencies, and school districts. Beginning with State fiscal year 1998, the Legislature established an annual fund of $750,000 for outreach grants. Grants have been awarded for a two-year period to 26 community-based organizations, public health and health organizations: 6 are to public agencies in the greater metropolitan area; 12 to public agencies and one to a private agency in rural areas of the state; six to agencies working with specific minority and ethnic communities in both metropolitan and outstate areas; one to the Minnesota News Network to develop a statewide media campaign; and one to the Minnesota Hospitals and Healthcare

Partnership to develop partnerships statewide between school districts and local hospitals.

The current targeted outreach efforts will include direct assistance in the application process to both English and non-English speaking populations; translation of program material (including application forms) for Asian and Pacific Islanders, Hmong, Somalis and Hispanics; media campaigns for minority populations; and will establish partnerships between community hospitals and schools to identify uninsured children.

Programs of the Minnesota Department of Health Because of the importance of health care coverage for the populations they serve, both the Title V and WIC programs are aggressive in their attempts to identify children who are uninsured or underinsured; and to assist families in determining what public/private program best meets their needs, assist the family through the application process, and assist families in obtaining access to services once eligibility has been established. This is accomplished by:

Requiring MCH grantees to discuss health care coverage with all clients

1-800 telephone hotline for children with special health care needs that discusses financial constraints parents may have and assist families to identify appropriate public or private sources.

Use of the same application by MinnesotaCare and Minnesota Children with Special Health Care needs.

Making available MinnesotaCare applications at Title V/WIC clinic sites.

The 300 WIC clinics throughout the state routinely discuss health care coverage issues with the families they serve.

Provide information on available public resources to general public through fliers and brochures.

Formal training for professionals about available public resources via Title V- sponsored workshops or ad hoc meetings.

In addition, grantees of Maternal and Child Health Special Project funds have specific outreach plans for high risk pregnant women, and strategies to assure complete prenatal care with includes referral for Medicaid eligibility determinations.

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

Program information is disseminated via all of the toll-free health care program phone lines (Medicaid, MinnesotaCare, Minnesota Children with Special Health Needs). The private insurance information sent to MinnesotaCare applicants who have income over 200% of poverty includes information on the MCHA program. Persons who apply for MCHA coverage within 90 days of the termination of benefits under a publicly funded health program (Medical Assistance, MinnesotaCare or General Assistance Medical Care) are not subject to the preexisting condition requirement, so long as the person remains a state resident.

2.3 Describe how the new State Title XXI program(s) is (are) designed to be coordinated with such efforts to increase the number of children with creditable health coverage so that only eligible targeted low-income children are covered: (Section 2102)(a)(3)

Coordination of the new group of eligible children will be accomplished through the use of the same application process and application form already in use in the Minnesota Health Care Programs. Information obtained in this process will establish whether the child is a targeted low-income child.

Section 3. General Contents of State Child Health Plan (Section 2102(a)(4))

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

3.1 Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children: (Section 2102)(a)(4)

3.2 Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children: (Section 2102 (a)(4)

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

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

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

4.1.1. Geographic area served by the Plan:

4.1.2. Age:

4.1.3. Income:

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

4.1.5. Residency:

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

4.1.7. Access to or coverage under other health coverage:

4.1.8. Duration of eligibility:

4.1.9. Other standards (identify and describe): 4.2 The state assures that it has made the following finding with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B))

4.2.1. These standards do not discriminate on the basis of diagnosis.

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

4.2.3. These standards do not deny eligibility based on a child having a preexisting medical condition.

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

4.4 Describe the procedures that assure:

4.4.1. Through intake and follow up screening, that only targeted low-income children who are ineligible for either

Medicaid or other creditable coverage are furnished child health assistance under the state child health plan. (Section 2102)(b)(3)(A))

4.4.2. That children found through the screening to be eligible for medical assistance under the state Medicaid plan under Title XIX are enrolled for such assistance under such plan. (Section 2102(b)(3)(B))

4.4.3. That the insurance provided under the state child health plan does not substitute for coverage under group health plans. (Section 2102)(b)(3)(C))

4.4.4. The provision of child health assistance to targeted low-income children in the state who are Indians (as defined in section 4© of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c). (Section 2102)(b)(3)(D))

4.4.5. Coordination with other public and private programs providing creditable coverage for low-income children. (Section 2102)(b)(3)(E))

Section 5. Outreach and Coordination (Section 2102)(c))

Describe the procedures used by the state to accomplish:

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

Outreach for this group of infants will be incorporated into current outreach efforts in Minnesota Medical Assistance, MinnesotaCare, and public health programs (community public health agencies, Title V programs).

5.2 Coordination of the administration of this program with other public and private health insurance programs: (Section 2102)(c)(2))

Section 6. Coverage Requirements for Children’s Health Insurance (section 2103)

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

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

6.1.1. Benchmark coverage; (Section 2103)(a)(1))

6.1.1.1.

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

6.1.1.2.

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

6.1.1.3.

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

6.1.2. Benchmark-equivalent coverage; (Section 2103(a)(2)) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach signed actuarial report that meets the requirements specified in Section 2103(c)(4). See instructions.

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

6.1.4. Secretary-Approved Coverage. (Section 2103(a)(4))

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

limitations) (Section 2110(a))

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

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

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

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

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

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

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

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

6.2.9. Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

6.3 Waivers - Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate waiver. Review and approval of the waiver application(s) will be distinct from the state plan approval process. To be approved, the state must address the following: (Section 2105(c)(2) and (3))

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

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

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

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

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

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

`

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

Section 7. Quality and Appropriateness of Care

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

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

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

7.1.1. Quality standards

7.1.2. Performance measurement

7.1.3. Information strategies

7.1.4. Quality improvement strategies

7.2 Describe the methods used, including monitoring, to assure access to covered services, including emergency services. (Section 2102(a)(7)(B))

Section 8. Cost Sharing and Payment (Section 2103(e))

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

8.1 Is cost-sharing imposed on any of the children covered under the plan?

8.1.1. YES

8.1.2. NO, skip to question 8.5.

8.2 Describe the amount of cost-sharing and any sliding scare based on income: (Section 2103(e)(1)(A))

8.2.1. Premiums:

8.2.2. Deductibles:

8.2.3. Coinsurance:

8.2.4. Other:

8.3 Describe how the public will be notified of this cost-sharing and any differences based on income:

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

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

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

8.4.3. No child in a family with income less than 150% of the Federal Poverty Level will incur cost-sharing that is not permitted under 1916(b)(1).

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

8.4.5. No premiums or cost-sharing will be used toward state matching requirements. (Section 2105(c)(5))

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

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

8.4.8. No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105(c)(7)(B))

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

8.5 Describe how the state will ensure that the annual aggregate cost- sharing for a family does not exceed 5 percent of such family’s annual income for the year involved: (Section 2103(c)(3)(B))

8.6 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan:

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

8.6.2. The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.3.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2109(a)(1),(2)). Please describe:

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

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

Expand access to health care insurance for uninsured infants.

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

Reduce the number of uninsured children in Minnesota by enrolling low income children under age two in the Medicaid program with income above 275% but equal to or less than 280% of the federal poverty level.

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

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

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

9.3.2. The reduction in the percentage of uninsured children.

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

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

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

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

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

9.3.7.1. X

Immunization

9.3.7.2.

Well child care

9.3.7.3.

Adolescent well visits

9.3.7.4.

Satisfaction with care

9.3.7.5.

Mental Health

9.3.7.6.

Dental Care

9.3.7.7. X Other, please list:

From the HEDIS measures being reported to the Department of Health in 1998, the following measures relevant to children under age two:

Use of Service Measures: Inpatient utilization, acute care and non-acute care; ambulatory care; births and average length of stay for newborns; percent receiving inpatient and ambulatory mental health services; inpatient discharges and average length of stay of mental health admissions; readmission for selected mental health disorders; and

Effectiveness of care measures: Prenatal care in the first trimester (in addition to childhood immunization).

9.3.8. X Performance measures for special targeted populations.

1. Improve the health of infants from birth to age two whose family income is greater than 275% of the federal poverty level, but is equal to or less than 280% of federal poverty, as measured by an increase in Medicaid enrollment of this age group.

2. Improve the health of children from birth to age 2 as measured by participation in EPSDT.

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

9.5 X The state assures it will comply with the annual assessment and evaluation required under Section 10.1 and 10.2. (See Section 10) Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2))

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

9.7 X The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed.

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

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

9.8.2. X Paragraphs (2), (16) and (17) of Section 1903(I) (relating to limitations on payment)

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

9.8.4. X Section 1115 (relating to waiver authority)

9.8.5. X Section 1116 (relating to administrative and judicial review), but only insofar as consistent with Title XXI

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

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

9.8.8. X Section 1128A (relating to civil monetary penalties)

9.8.9. X Section 1128B(d) (relating to criminal penalties for certain additional charges)

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

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

The public has been involved in the process of designing a Child Health Insurance Program through an advisory committee to the Department of Human Services and the legislative process.

In September, 1997, the Department of Human Services initiated dialogue with a committee of thirty-five stakeholders and other advocates for children to identify barriers to children’s access to health care and to explore strategies for addressing those barriers under the Child Health legislation. The committee convened several times between September and December of 1997. The committee consists of representatives from advocacy organizations for children, including disability advocacy, ethnic community organizations, and legal advocacy; the Minnesota Department of Health; community health facilities, medical provider associations and managed care organizations. Attachment 2 is a list of committee participants.

The following were identified by the committee as common barriers to children obtaining health care coverage:

Families at lowest income levels have difficulty paying the monthly MinnesotaCare premiums

Lack of transportation to application sites

Difficulties in completing application forms and understanding the process

Asset limit in Medical Assistance

Insurance barriers in MinnesotaCare

Language barriers

The Committee received a copy of the Governor’s Supplement Budget Recommendation on health care for children prior to the 1998 State legislative session. The Department continues to involve the committee in ongoing child health planning activity. Most recently, the committee was included in an April 1, 1998 session to address strategies on outreach.

The Minnesota Legislature convened on January 19, 1998 for the second half of its biennial session, and adjourned on April 9, 1998. During the session, bills for Child Health Insurance programs were introduced in both houses, considered in public committee hearings, and passed both houses. A conference committee agreement on Child Health Insurance initiatives was adopted by the Legislature. The legislation was signed by the Governor on April 21,1998. The expansion of Medicaid for children under two was specifically considered by numerous committees in both the House and Senate, and is contained in the law as enacted.

9.10 Provide a budget for this program. Include details on the planned use of funds and sources on the non-Federal share of plan expenditures. (Section 2107(d))

FY 1999 FY 2000 FY 2001

Number of Eligibles

5 12

12

Avg. Monthly payment

$ 490.75 $ 513.32 $ 538.48

Total Payments

$26,584.00 $74,153.00 $77,541.00 With Enhanced FMAP under Title XXI:

State share

$ 8,015.00 $22,357.00 $23,541.00

County share

$ 891.00 $ 2,484.00 $ 2,598.00

Federal share

$17,679.00 $49,312.00 $51,565.00

Section 10. Annual Reports and Evaluations (Section 2108)

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

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

10.1.2. X Report to the Secretary, January 1 following the end of the fiscal year, on the result of the assessment.

10.2 X State Evaluations. The state assures that by March 31, 2000 it will submit to the Secretary an evaluation of each of the items described and listed below: (Section 2108(b)(A)- (H))

10.2.1. X An assessment of the effectiveness of the state plan in increasing the number of children with creditable health coverage.

10.2.2. X A description and analysis of the effectiveness of elements of the state plan, including:

10.2.2.1. X The characteristics of the children and families assisted under the state plan including age of the children, family income, and the assisted chid’s access to or coverage by other health insurance prior to the state plan and after eligibility for the state plan ends;

10.2.2.2. X The quality of health coverage provided including the types of benefits provided;

10.2.2.3. X The amount and level (including payment of part or all of any premium) of assistance provided by the state;

10.2.2.4. X The service area of the state plan;

10.2.2.5. X The time limits for coverage of a child under the state plan;

10.2.2.6. X The state’s choice of health benefits coverage and other methods used for providing child health assistance, and

10.2.2.7. X The sources of non-Federal funding used in the state plan.

10.2.3. X An assessment of the effectiveness of other public and private programs in the state in increasing the availability of affordable quality individual and family health insurance for children.

10.2.4. X A review and assessment of state activities to coordinate the plan under this Title with other public and private programs providing health care and health care financing, including Medicaid and maternal and child health services.

10.2.5. X An analysis of changes and trends in the state that affect the provision of accessible, affordable, quality health insurance and health care to children.

10.2.6. X A description of any plans the state has for improving the availability of health insurance and health care for children.

10.2.7. X Recommendations for improving the program under this Title.

10.2.8. X Any other matters the state and the Secretary consider appropriate.

10.3 X The state assures it will comply with future reporting requirements as they are developed.

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

MINNESOTA’S TITLE XXI PROGRAM FACT SHEET

Name of Plan:

Minnesota’s Children’s Health Insurance Plan

Date of Plan Submission:

April 29, 1998 Date Plan Approved:

June 17, 1998 Effective Date for Plan:

September 30, 1998

Date Amendment #1 Submitted: June 24, 2002 Date Amendment #1 Approved: October 11, 2002 Date Amendment #1 Effective: July 1, 2001

Date Amendment #2 Submitted: May 15, 2002 Date Amendment #2 Approved: August 6, 2003 Date Amendment #2 Effective: November 1, 2002

Date Amendment #3 Submitted: April 26, 2004 Date Amendment #3 Approved: Withdrawn June 18, 2004 Date Amendment #3 Effective: July 1, 2004

Date Amendment #4 Submitted: September 16, 2009 Date Amendment #4 Approved:

Date Amendment #4 Effective: July 1, 2009

Date Amendment #5 Submitted: May 25, 2010 Date Amendment #5 Approved:

Date Amendment #5 Effective: July 1, 2010

Background

Minnesota’s Title XXI plan expands Medicaid coverage to children under age 2 in families with incomes above 275 percent of the Federal poverty level (FPL) and at or below 280 percent of the FPL.

Amendments

• On June 24, 2002, Minnesota submitted a State plan amendment to indicate the State’s compliance with the final SCHIP regulations and to update program descriptions and to implement a health services initiative under the State’s 10-percent administrative cap. The health services initiative includes:

° Mental health screenings of children in the court system -- The State will provide grants to local agencies to offer screenings for children who are in the juvenile court system. ° Outreach and mental health screenings for homeless children -- The State will provide grants to local agencies to provide outreach and mental health screenings to homeless children.

° Comprehensive services for children with special health care needs -- The State will offer comprehensive services to children without health insurance coverage and supplemental services to children with inadequate health insurance. ° Family planning services -- The State will provide grants to provide outreach, education and family planning services for uninsured teens.

None of these programs will be used to provide services for children enrolled in Medicaid.

• On May 14, 2003, Minnesota submitted a second amendment to its title XXI State Plan to add coverage for unborn children with family incomes at or below 275 percent of the FPL and not eligible for Medicaid. Coverage is under a separate child health program and will include prenatal care and associated health services for children from conception through birth. Upon birth, the child will be screened for Medicaid and SCHIP and enrolled in the appropriate program.

• On April 26, 2004 Minnesota submitted a third amendment to request a reduction in the income level of the unborn group from 275 to 200 percent of the FPL. This amendment was withdrawn on June 18, 2004.

• On September 16, 2009 Minnesota submitted a fourth amendment to its title XXI State plan to add coverage of postpartum services under the unborn option.

• On May 25, 2010 Minnesota submitted a fifth amendment to expand coverage to non- citizen children under section 214 of CHIPRA.

Children Covered Under Program

5,470 children were ever enrolled in FY 2009.

Administration

The Minnesota Department of Human Services administers the program.

Health Care Delivery System

Care is provided through the current Medicaid managed care delivery system.

Benefit Package

The current Medicaid benefit package is provided.

Cost Sharing

There is no cost sharing.

Crowd-Out Strategy

Crowd-out of private insurance is monitored at the point of application. The State does not believe that the possibility of crowd-out is reduced as the separate program covers the unborn population only.

Outreach Activities

Because this expansion builds off of the current Medicaid program, Minnesota utilizes many of the already existing resources to inform and enroll potential eligibles. These outreach efforts include: ° A toll-free number for program inquiries and eligibility questions. ° Application forms available at various community sites such as provider offices, school districts, public and private elementary schools, community health offices, WIC program sites and local human service agencies. ° Targeted outreach efforts including media campaigns, partnerships between community hospitals and schools to identify uninsured children, and discussions with employers not offering health care coverage.

Financial Information

Total FFY 2010 SCHIP Allotment -- $87,896,693 FFY 2010 Enhanced Federal Matching Rate – 65.00%

Date Last Updated: August 16, 2010

_____________________________________________________________________________

Table of Contents

State/Territory Name: Minnesota

State Plan Amendment (SPA) #: MN-13-0006

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

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: $2-26-12

Children and Adults Health Programs Group

JAN 15 2014 Ms. Pat Callaghan

MN Department of Human Services P.O. Box 64983 St. Paul, MN 55164-0983

Dear Ms. Callaghan:

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers MN-13-0006, MN-13-0007 and MN-13-0008 submitted on November 7, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility, have been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

SPA number MN 13-0006 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and, using the approved MAGI conversion plan income thresholds, the state indicates on page CS9 that it will cover children from conception to birth when the mother is not eligible for Medicaid. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS9 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan.

XXI Medicaid Expansion

SPA number MN-13-0007 converts the state’s existing income eligibility standards to modified adjusted gross income (MAGI)-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Establish 2101(f) Group:

SPA number MN-13-0008 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Minnesota’s approved CHIP state plan.

Page 2 — Ms. Pat Callaghan

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

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Division of State Coverage Programs

Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-5913

Facsimile: (410) 786-5882

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

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Office of the Regional Administrator

233 North Michigan Avenue, Suite 600

Chicago, Illinois 60601

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

Sincerely,

10t Fis, Director

Enclosures ce: Ms. Verlon Johnson, CMS Region V, Chicago

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MN.0478.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Minnesota State Funds: $ Federal Funds: $ Submitted By: Pat Callaghan Last Revision Date: Dec 18, 2013 Submit Date: Nov 7, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. MN 13-0006 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2102(b) of the Social Security Act; 42 CFR 457.10. Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:112 out of 2000 New templates for MAGI eligibility & methods: CS9 for unborn children; CS15 for implementation of MAGI methods. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CHIP Eligibility

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

42 CFR 457.10

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

From conception through birth.

uv Does the state have an additional age definition or other age-related conditions?

Income Standards

Income standards are applied statewide.

Are there any exceptions. ¢.g. populations in a county which may qualify under either a statewide income standard or a county income standard?

No

Statewide Income Standard

The statewide income standard is: From zero up to {278 | % FPL

[i] Exempted from requirement of providing or applying for a Social Security Number.

{@) Exempted from requirement of verifying citizenship status.

Statement

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

JAN 15 2014

SPA# MN-13-0006 Approval Date: Effective Date: January 1, 2014

Page | of |

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

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

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

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

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

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

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

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

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

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

SPA# MN-13-0006 Approval Date:

PRA Disclosure Statement JAN 15 2014

Effective Date: January 1, 2014 Page | of 2

Fn a

TEMS. CHIP Eligibility

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

JAN 15 2014

SPA# MN-13-0006 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

cms. CHIP Eligibility

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

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

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

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL.) 2 275 283 P. isclosure Statement

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

SPA# MN-13-0007 Approval Date: JAN i 5 2014

Effective Date: January 1, 2014 ©

Page | of 1

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

7

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

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

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(0 such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected

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

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

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

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

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

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

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

@ Other.

The state will identify children protected by Section 2101(f) and enroll such children in a separate CHIP based on the following methodology and procedures as approved by CMS.

Until 1/1/2014, the state covered children age two up to age 19 under the Medicaid State Plan with a net income test up to 150% of the federal poverty level, and children under a Medicaid section 1115 waiver program with family gross income up to 275% of poverty. Because the Medicaid-elected income standard for children under age 19 will be 275 % of the federal poverty level on 1/1/2014, it-is anticipated that the elimination of income disregards will affect very few children. At renewal or redetermination of Medicaid eligibility, workers will be instructed before terminating children to evaluate whether family income might have been reduced below 275% by earned income disregards, and other larger amounts such as child support paid or multiple children with child care expenses.

JAN 15 2014

SPA# MN-13-0008 Approval Date: Effective Date: January 1, 2014

Page | of 2

CcMs. CHIP Eligibility

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

C Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP.

@ No premiums. copayments, deductibles, coinsurance or other cost sharing is required.

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

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

JAN 15 2014

SPA# MN-13-0008 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Minnesota

State Plan Amendment (SPA) #: MN-13-0007

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

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: $2-26-12

Children and Adults Health Programs Group

JAN 15 2014 Ms. Pat Callaghan

MN Department of Human Services P.O. Box 64983 St. Paul, MN 55164-0983

Dear Ms. Callaghan:

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers MN-13-0006, MN-13-0007 and MN-13-0008 submitted on November 7, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility, have been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

SPA number MN 13-0006 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and, using the approved MAGI conversion plan income thresholds, the state indicates on page CS9 that it will cover children from conception to birth when the mother is not eligible for Medicaid. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS9 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan.

XXI Medicaid Expansion

SPA number MN-13-0007 converts the state’s existing income eligibility standards to modified adjusted gross income (MAGI)-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Establish 2101(f) Group:

SPA number MN-13-0008 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Minnesota’s approved CHIP state plan.

Page 2 — Ms. Pat Callaghan

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

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Division of State Coverage Programs

Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-5913

Facsimile: (410) 786-5882

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

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Office of the Regional Administrator

233 North Michigan Avenue, Suite 600

Chicago, Illinois 60601

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

Sincerely,

Eliot Fishman Director

Enclosures ce: Ms. Verlon Johnson, CMS Region V, Chicago

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MN.0479.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Minnesota State Funds: $ Federal Funds: $ Submitted By: Pat Callaghan Last Revision Date: Nov 7, 2013 Submit Date: Nov 7, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. MN-13-0007 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:215 out of 2000 New template CS3 for CHIP Medicaid expansion group; MAGI-based income standard for CHIP Medicaid expanstion group from birth up to age 2. Note: Tribal input documentation for this SPA is included in SPA MN- 13 0006 Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_179.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_179.jsp

CHIP Eligibility

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

42 CFR 457.10

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

From conception through birth.

uv Does the state have an additional age definition or other age-related conditions?

Income Standards

Income standards are applied statewide.

Are there any exceptions. ¢.g. populations in a county which may qualify under either a statewide income standard or a county income standard?

No

Statewide Income Standard

The statewide income standard is: From zero up to {278 | % FPL

[i] Exempted from requirement of providing or applying for a Social Security Number.

{@) Exempted from requirement of verifying citizenship status.

Statement

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

JAN 15 2014

SPA# MN-13-0006 Approval Date: Effective Date: January 1, 2014

Page | of |

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

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

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

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

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

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

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

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

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

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

SPA# MN-13-0006 Approval Date:

PRA Disclosure Statement JAN 15 2014

Effective Date: January 1, 2014 Page | of 2

Fn a

TEMS. CHIP Eligibility

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

JAN 15 2014

SPA# MN-13-0006 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

cms. CHIP Eligibility

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

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

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

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL.) 2 275 283 P. isclosure Statement

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

SPA# MN-13-0007 Approval Date: JAN i 5 2014

Effective Date: January 1, 2014 ©

Page | of 1

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

7

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

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

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(0 such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected

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

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

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

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

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

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

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

@ Other.

The state will identify children protected by Section 2101(f) and enroll such children in a separate CHIP based on the following methodology and procedures as approved by CMS.

Until 1/1/2014, the state covered children age two up to age 19 under the Medicaid State Plan with a net income test up to 150% of the federal poverty level, and children under a Medicaid section 1115 waiver program with family gross income up to 275% of poverty. Because the Medicaid-elected income standard for children under age 19 will be 275 % of the federal poverty level on 1/1/2014, it-is anticipated that the elimination of income disregards will affect very few children. At renewal or redetermination of Medicaid eligibility, workers will be instructed before terminating children to evaluate whether family income might have been reduced below 275% by earned income disregards, and other larger amounts such as child support paid or multiple children with child care expenses.

JAN 15 2014

SPA# MN-13-0008 Approval Date: Effective Date: January 1, 2014

Page | of 2

CcMs. CHIP Eligibility

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

C Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP.

@ No premiums. copayments, deductibles, coinsurance or other cost sharing is required.

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

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

JAN 15 2014

SPA# MN-13-0008 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Minnesota

State Plan Amendment (SPA) #: MN-13-0008

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

This file contains the following documents in the order listed:

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

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

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: $2-26-12

Children and Adults Health Programs Group

JAN 15 2014 Ms. Pat Callaghan

MN Department of Human Services P.O. Box 64983 St. Paul, MN 55164-0983

Dear Ms. Callaghan:

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbers MN-13-0006, MN-13-0007 and MN-13-0008 submitted on November 7, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility, have been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

SPA number MN 13-0006 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and, using the approved MAGI conversion plan income thresholds, the state indicates on page CS9 that it will cover children from conception to birth when the mother is not eligible for Medicaid. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS9 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan.

XXI Medicaid Expansion

SPA number MN-13-0007 converts the state’s existing income eligibility standards to modified adjusted gross income (MAGI)-equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Establish 2101(f) Group:

SPA number MN-13-0008 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Minnesota’s approved CHIP state plan.

Page 2 — Ms. Pat Callaghan

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

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Division of State Coverage Programs

Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-5913

Facsimile: (410) 786-5882

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

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Office of the Regional Administrator

233 North Michigan Avenue, Suite 600

Chicago, Illinois 60601

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

Sincerely,

Eliot Fishman Director

Enclosures ce: Ms. Verlon Johnson, CMS Region V, Chicago

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MN.0480.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Minnesota State Funds: $ Federal Funds: $ Submitted By: Pat Callaghan Last Revision Date: Nov 7, 2013 Submit Date: Nov 7, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. MN-13-0008 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2101(f) of the Social Security Act Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:211 out of 2000 New template CS14 for new coverage group of children losing Medicaid eligibilty as a reuslt of discontinuation of income disregards. Note: Tribal input documentation for this SPA is included in SPA MN 13 0006 Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CHIP Eligibility

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

42 CFR 457.10

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

From conception through birth.

uv Does the state have an additional age definition or other age-related conditions?

Income Standards

Income standards are applied statewide.

Are there any exceptions. ¢.g. populations in a county which may qualify under either a statewide income standard or a county income standard?

No

Statewide Income Standard

The statewide income standard is: From zero up to {278 | % FPL

[i] Exempted from requirement of providing or applying for a Social Security Number.

{@) Exempted from requirement of verifying citizenship status.

Statement

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

JAN 15 2014

SPA# MN-13-0006 Approval Date: Effective Date: January 1, 2014

Page | of |

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

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

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

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

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

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

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

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

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

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

SPA# MN-13-0006 Approval Date:

PRA Disclosure Statement JAN 15 2014

Effective Date: January 1, 2014 Page | of 2

Fn a

TEMS. CHIP Eligibility

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

JAN 15 2014

SPA# MN-13-0006 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

cms. CHIP Eligibility

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

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

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

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL.) 2 275 283 P. isclosure Statement

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

SPA# MN-13-0007 Approval Date: JAN i 5 2014

Effective Date: January 1, 2014 ©

Page | of 1

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

7

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

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

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(0 such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected

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

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

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

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

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

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

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

@ Other.

The state will identify children protected by Section 2101(f) and enroll such children in a separate CHIP based on the following methodology and procedures as approved by CMS.

Until 1/1/2014, the state covered children age two up to age 19 under the Medicaid State Plan with a net income test up to 150% of the federal poverty level, and children under a Medicaid section 1115 waiver program with family gross income up to 275% of poverty. Because the Medicaid-elected income standard for children under age 19 will be 275 % of the federal poverty level on 1/1/2014, it-is anticipated that the elimination of income disregards will affect very few children. At renewal or redetermination of Medicaid eligibility, workers will be instructed before terminating children to evaluate whether family income might have been reduced below 275% by earned income disregards, and other larger amounts such as child support paid or multiple children with child care expenses.

JAN 15 2014

SPA# MN-13-0008 Approval Date: Effective Date: January 1, 2014

Page | of 2

CcMs. CHIP Eligibility

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

C Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP.

@ No premiums. copayments, deductibles, coinsurance or other cost sharing is required.

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

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

JAN 15 2014

SPA# MN-13-0008 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Minnesota

State Plan Amendment (SPA) #: MN-13-0009

This file contains the following documents in the order listed:

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

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

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

7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Fod ¢ 2 2014 Ms. Pat Callaghan MN Department of Human Services

P.O. Box 64983 St. Paul, MN 55164-0983

Dear Ms. Callaghan:

lam pleased to inform you that Minnesota’s Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), MN-13-0009, submitted on November 7, 2013, has been approved. This SPA incorporates the MAGI-based eligibility process requirements in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

Through July 1, 2014, the state is using interim alternative single streamlined paper and online applications. The state will implement the revised paper and online applications that address our concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the end of Minnesota’s approved CHIP State Plan:

CS24 Attachment 1 — Statement of use with respect to the alternative single streamlined paper application

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

This approval and the attachments supercede the following sections of the current CHIP State Plan:

e Section 4.3: Single, Streamlined Application Screen and Enroll Process e Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your title XXI project officer is Ms. Kathleen Cuneo. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Cuneo’s contact information is as follows:

Page 2 — Ms. Pat Callaghan

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

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-5913

Facsimile: (410) 786-5882

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

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

Ms. Verlon Johnson

Office of the Regional Administrator 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601

If you have additional questions, please contact Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143.

We look forward to continuing to work with you and your staff.

Sincerely,

Eliot Fishman Director

ce: Ms. Verlon Johnson, ARA, CMS Region V, Chicago

DEPARTMENT OF HEALTH & HUMAN SERVICES aad Centers for Medicare & Medicaid Services of M Sy, 7500 Security Boulevard, Mail Stop: S2-26-12

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

Children and Adults Health Programs Group

FEB 19 2014

Ms. Pat Callaghan

MN Department of Human Services P.O. Box 64983

St. Paul, MN 55164-0983

RE: C824 - Eligibility Process State Plan Amendment (SPA), MN-13-0009 Dear Ms. Callaghan:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of Minnesota’s state plan amendment (SPA) transmittal MN-13-0009, which was submitted to CMS on November 7, 2013. Our review of this submission included a review of both the alternative single streamlined paper and on line application developed by the state.

Through July 1, 2014, the state is using interim alternative single streamlined paper applications. The interim applications must be revised to reflect the following changes:

Necessary Changes Date by which changes will be completed: Paper alternative single streamlined July 1, 2014

application: Questions regarding tobacco use will not appear.

Online alternative single streamlined July 1, 2014 application: Questions regarding whether each

person plans to make Minnesota their home will not appear for household members not seeking any benefits.

Please submit the revised alternative single streamlined online application to CMS for review no later than June 1, 2014, to ensure approval by July 1, 2014. We continue to be available to provide technical assistance. For technical assistance with your application, please contact Victoria Collins at Victoria.Collins@cms.hhs.gov or (410) 786-2167.

Page 2 — Ms. Pat Callaghan

We look forward to continuing to work with you and your staff.

Sincerely,

Linda Nablo Director, Division of State Coverage Programs

ce: Ms. Verlon Johnson, ARA, CMS Region V, Chicago

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

lPaper Application OOnline Application TRANSMITTAL NUMBER: STATE: MN-13-0009 Minnesota

Through June 30,2014, the state is using an interim paper alternative single streamlined application. As of July 1, 2014, the state will use a revised online alternative single streamlined application. The revised application will address the issues outlined in the CMS companion 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.

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application Online Application

TRANSMITTAL NUMBER: STATE:

MN-13-0009 Minnesota

Through June 30,2014, the state is using an interim online alternative single streamlined application. As of July 1, 2014, the state will use a revised online alternative single streamlined application. The revised application will address the issues outlined in the CMS companion 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.

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MN.0481.R00.00 - Oct 01, 2103 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Minnesota State Funds: $ Federal Funds: $ Submitted By: Pat Callaghan Last Revision Date: Jun 18, 2014 Submit Date: Nov 7, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. MN-13-0009 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 10/01/2103 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:364 out of 2000 New tempate CS24 for application process using a single streamlined form. Notes: The state uses a common or shared eligibility service for eligibilty determinations in all insurance affordability programs d th f h d f t t hi th Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 11/02/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

ccms. CHIP Eligibility

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

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

Application Processing

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

oO The single, ‘streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act.

An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with

SZ us section 1413(b)(1)(B) of the Affordable Care Act.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the (C1) agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

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 CF R 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means. (2) Other electronic means: Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low-

iJ income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

Procedures include:

fal Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs; and

i Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability ie on household income; and

SPA# MN-13-0009 Approval Date: Effective Date: October 1, 2013 Page 1 of 2

CHIP Eligibility

ia Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single streamlined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced Yes premium tax credits in accordance with section 1943(b)(2) of the SSA. "

Redetermination Processing

Redeterm inations 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 457.343:

[HM] Once every 12 months.

i 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.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals : screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42 CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering o insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42

CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP.

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the 0 requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

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

V.20130709

SPA# MN-13-0009 Approval Date: FEB 19 2014

Effective Date: October 1, 2013

Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Minnesota

State Plan Amendment (SPA) #: MN-13-0010

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

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

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

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

CCMS

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

Children and Adults Health Programs Group

Ms. Pat Callaghan

MN Department of Human Services P.O. Box 64983

St. Paul, MN 55164-0983

Dear Ms. Callaghan:

FEB 0 § 2014

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number MN-13-0010 submitted on November 7, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligibility has been approved with an effective date

of January 1, 2014.

SPA number MN-13-0010 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, and non-payment of premiums. Copies of the approved state plan pages are attached and these approved pages supersede sections of Minnesota’s current state plan as detailed below:

New State Plan Page

Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency

Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship

Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security

Number

Section 4.1.9.1

C820: Non-Financial Eligibility — Substitution of

Coverage

Section 4.4.4

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

as follows:

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

Division of State Coverage Programs

Mail Stop S2-01-16

7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-5913 Facsimile: (410) 786-5882

Page 2 — Ms. Pat Callaghan

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

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Office of the Regional Administrator

233 North Michigan Avenue, Suite 600

Chicago, Illinois 60601

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

Sincerely,

Eliot Fishman Director

Enclosures cc: Ms. Verlon Johnson, CMS Region V, Chicago

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MN.0482.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Minnesota State Funds: $ Federal Funds: $ Submitted By: Pat Callaghan Last Revision Date: Jan 28, 2014 Submit Date: Nov 7, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. MN-13-0010 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320; sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:236 out of 2000 New templates: CS17 on state residence; CS18 on citizenship and noncitizen documentation, and coverge of lawfully residing; and CS19 on verification of SSN. Note: Tribal input documentation for this SPA is included in SPA MN 13 0006 Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

42 CFR 457.320

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

Residency

w

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

certain conditions. A child is considered to be a resident of the state under the following conditions: A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and: 1. Intends to reside in the state, including without a fixed address, or 2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [i] A non-institutionalized child not described above and a child who is not a ward of the state: 1. Residing in the state, with or without a fixed address, or 2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides. ry An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

{i A child who is a ward of the state regardless of where the child lives, or

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

fl

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

residence.

[@] A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

rl An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes. by an agency of the state, or

rl An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's

fl actual state of residence.

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

Approval Date: FEB 0 § 2014 Effective Date: January 1, 2014 Page | of 2

SPA# MN-13-0010

CHIP Eligibility

CNTR OR NERC 4 <a AAD SERN

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes.

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

FEB 0 5 2014

SPA# MN-13-0010 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

rCcCMSsS CHIP Eligibility

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

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, [7] including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[i] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals: Who are citizens or nationals of the United States; or

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

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

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

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

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

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

“@ Other date, as described:

The start date of eligibility (per the Medicaid State Plan, Attachment 2.6-A, item 11.(a) p. 24).

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

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

[¥] The CHIP Agency provides assurance that lawfully residing childyen iN also covered under the state's Medicaid program. 1k. SPA# MN-13-0010 Approval Date: reo vy ev Effective Date: January 1, 2014

Page | of 3

CHIP Eligibility

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

No

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

[i] An individual is considered to be lawfully present in the United States if he or she is:

1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

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

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

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

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

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

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

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

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

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

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

(i) Has been granted employment authorization; or

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

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

SPA# MN-13-0010 Approval Date: FEB 0 5 2014 Effective Date: January 1, 2014 Page 2 of 3

s CHIP Eligibility

IANO ANT TANT MERE

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

10.

definition.

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

Approval Date: FEB 0 5 2014 Effective Date: January 1, 2014 Page 3 of 3

SPA# MN-13-0010

CHIP Eligibility

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

42 CFR 457.340(b)

Social Security Number As a condition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

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

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

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

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

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205

and 1137 of the Social Security Act and the Privacy Act of 1974.

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

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

When requesting an SSN for non-applicant household members, the state assures that:

aw At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

ial The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

SPA# MN-13-0010 Approval Date: FEB 05 2014

Effective Date: January 1, 2014

Page | of 2

CMs. CHIP Eligibility

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

FEB 0 § 2014

SPA# MN-13-0010 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

OMB Control Number: 0938-1148

Xpiration dat 1/31/2014

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

Substitution of Coverage

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

[H] Substitution of coverage prevention strategy:

Name of policy Description

Uninsured status A condition of eligibility is that the person not have any other creditable coverage.

Minnesota only covers unborn children in its separate CHIP, and does not have a substitution strategy for this population because the majority of pregnant women are undocumented women without access to health insurance.

A waiting period during which an individual is ineligible due to having dropped group health coverage. [7] If the state covers pregnant women, the waiting period does not apply to pregnant women.

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

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

([) The waiting period does not apply to children eligible for dental only supplemental coverage.

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

V.20130718

SPA# MN-13-0010 Approval Date: FEB Q & 2046 Effective Date: January 1, 2014

Page | of |

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Minnesota MN-17-0012

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Securig Boulevard, Mail Stop 32-01-'16 Baltirnore, MD 21244-1850 Children and Adults Heâlfh lvts ctN¡¡Rit ro8 M¡D¡cÀß[ & MrDtcltD stßvtcts cENr¡l fon i,tEDtcAtD & clltp sfnvtcEs Group AUG I 6 2018 Ms. Marie Zimmerman State Medicaid Director Minnesota Department of Human Services Health Care Administration P.O. Box 64983 Saint Paul, MN 55164-0983 Dear Ms. Zimmerman: Your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) MN- 17-0012 has been approved. MN-17-0012 implements mental health parity requirements in section 2103(c)(6) of the Social Security Act (the Act) and regulations at 42 CFR 457.496 to ensure that treatment limitations and financial requirements applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical (M/S) benefits. This SPA has an effective date of October 2,2017. Section 2103(c)(6)(A) of the Social Security Act (the Act) requires that, to the extent that a state provides both M/S benefits and MH/SUD benefits, a state child health plan must ensure that fìnancial requirements and treatment limitations applicable to MH/SUD benefits comply with the mental health parity requirements of section2705(a) of the Public Health Service Act inthe same manner that such requirements apply to a group health plan. Under this SPA, Minnesota requested deemed compliance for the unborn population whose mothers are under age 21, and conducted a full parity analysis for the unborn population whose mothers are age 2l and older. This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analy zed separately. Unborn population whose mothers øre under age 21 Section 2103(c)(6)(B) of the Act, as implemented through regulations at 42 CFR 457.496(b), provides that if CHIP coverage includes the Early, Periodic Screening, Diagnostic and Treatment (EPSDT) benefit as defined in section 1905(r) of the Act and provided in accordance with section 1902({(a3) of the Act, the state plan will be deemed to satisfy parity requirements. Minnesota has provided the necessary assurances and supporting documentation that EPSDT is covered under Minnesota's CHIP program and provided in accordance with sections 1905(r) and 1902(a)(a3) of the Act.

Page2 - Ms. Marie Zimmerman Unborn populatìon whose mothers are øge 2l and older The state also conducted a full parity analysis relative to its application of non-quantitative treatment limitations (NQTLs) for MH or SUD benefits consistent with section 2103(c)(6XA) of the Act, as implemented through regulations at42 CFR 457.496(dX4) and 42 CFR 457.496(d)(5). In addition, the state demonstrated compliance through providing the necessary assurances in section 6.2.6.1- MHPAEA, and supporting documentation describing the state's comparison analysis of NQTLs. During the review of the NQTL analysis of the CHIP SPA, Minnesota also conveyed that broader reform eflbrts are underway in the state related to the health care delivery system for Medicaid and CHIP enrollees seeking SUD treatment and services. Your title XXI project officer is Ms. Michelle Wojcicki. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Wojcicki's contact information is as ftrllows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1 850 Telephone: (4 I 0) 786-0306 E-mail: michelle.wojcickil @cms.hhs.gov Offìcial communications regarding program matters should be sent simultaneously to Ms. Wojcicki and to Ms. Ruth Hughes, Associate Regional Administrator in our Chicago Regional Office. Ms. Hughes' address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations 233 North Michigan Avenue, Suite 600 Chicago, IL 60601 We look forward to continuing to work with you and your staff. Si ly, Marie Director Enclosures cc: Ms. Ruth Hughes, ARA, CMS Region V, Chicago /Signed by Anne Marie Costello/

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

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

State/Territory: Minnesota

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

______________________ Ann Berg, Deputy Medicaid Director (Signature of Governor, or designee, of State/Territory, Date Signed)

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

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

Name: Julie Marquardt

Position/Title: Medicaid & Health Care Purchasing Director Name: Nathan Moracco

Position/Title: Assistant Commissioner, Health Care

Name: Alexandra Kotze

Position/Title: Chief Operations Officer, Financial

*Disclosure. 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 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

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

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

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

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage;

4 benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

5

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

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

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

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State

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

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

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

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

Original Plan Effective Date: September 30, 1998

Implementation Date: September 30, 1998

SPA #12 Purpose of SPA: Mental Health Parity compliance Proposed effective date: October 2, 2017

Proposed implementation date: October 2, 2017

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. Not applicable; this amendment has no direct impact on Indian health programs or Urban Indian Organizations.

Submissions Approval date

Effective/implementation date Plan:

July 17, 1998

September 30, 1998 Amendment #1: October 11, 2002

July 1, 2001 Amendment #2: August 6, 2003

November 2, 2002 Amendment #4: November 19, 2013 July 1, 2009 Amendment #5: September 20, 2010 July 1, 2010 Amendments 6-10: January 15, 2014 & February 5 & 19, 2014 January 1, 2014 Amendment 11: August 29, 2014

July 1, 2014 Amendment 12:

October 2, 2017

7 Section 6. Coverage Requirements for Children’s Health Insurance

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan and proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT.

6.1. The State elects to provide the following forms of coverage to children: (Check all that apply.) (Section 2103(c)); (42 CFR 457.410(a))

Guidance: Benchmark coverage is substantially equal to the benefits coverage in a benchmark benefit package (FEHBP-equivalent coverage, State employee coverage, and/or the HMO coverage plan that has the largest insured commercial, non-Medicaid enrollment in the state). If box below is checked, either 6.1.1.1., 6.1.1.2., or 6.1.1.3. must also be checked. (Section 2103(a)(1))

6.1.1.

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

Guidance: Check box below if the benchmark benefit package to be offered by the State is the standard Blue Cross/Blue Shield preferred provider option service benefit plan, as described in and offered under Section 8903(1) of Title 5, United States Code. (Section 2103(b)(1) (42 CFR 457.420(b))

6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1) (42 CFR 457.420(a)) (If checked, attach copy of the plan.)

Guidance: Check box below if the benchmark benefit package to be offered by the State is State employee coverage, meaning a coverage plan that is offered and generally available to State employees in the state. (Section 2103(b)(2))

6.1.1.2.

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

Guidance: Check box below if the benchmark benefit package to be offered by the State is offered by a health maintenance organization (as defined in Section 2791(b)(3) of the Public Health Services Act) and has the largest insured commercial, non-Medicaid enrollment of covered lives of such coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42 CFR 457.420(c)))

6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If

8 checked, identify the plan and attach a copy of the benefits description.)

Guidance: States choosing Benchmark-equivalent coverage must check the box below and ensure that the coverage meets the following requirements:  the coverage includes benefits for items and services within each of the categories of basic services described in 42 CFR 457.430: • dental services • inpatient and outpatient hospital services, • physicians’ services, • surgical and medical services, • laboratory and x-ray services, • well-baby and well-child care, including age-appropriate immunizations, and • emergency services;  the coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages (FEHBP-equivalent coverage, State employee coverage, or coverage offered through an HMO coverage plan that has the largest insured commercial enrollment in the state); and  the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the additional categories in such package, if offered, as described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services.

If 6.1.2. is checked, a signed actuarial memorandum must be attached. The actuary who prepares the opinion must select and specify the standardized set and population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The State must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State results.

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences

9 in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

6.1.2.

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

Guidance: A State approved under the provision below, may modify its program from time to time so long as it continues to provide coverage at least equal to the lower of the actuarial value of the coverage under the program as of August 5, 1997, or one of the benchmark programs. If “existing comprehensive state-based coverage” is modified, an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997, or one of the benchmark plans must be attached. Also, the fiscal year 1996 State expenditures for “existing comprehensive state-based coverage” must be described in the space provided for all states. (Section 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997 or one of the benchmark plans. Describe the fiscal year 1996 State expenditures for existing comprehensive state- based coverage.

Guidance: Secretary-approved coverage refers to any other health benefits coverage deemed appropriate and acceptable by the Secretary upon application by a state. (Section 2103(a)(4)) (42 CFR 457.250)

6.1.4. X

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) Guidance: Section 1905(r) of the Act defines EPSDT to require coverage of (1) any medically necessary screening, and diagnostic services, including vision, hearing, and dental screening and diagnostic services, consistent with a periodicity schedule based on current and reasonable medical practice standards or the health needs of an individual child to determine if a suspected condition or illness exists; and (2) all services listed in section 1905(a) of the Act that are necessary to correct or ameliorate any defects

10 and mental and physical illnesses or conditions discovered by the screening services, whether or not those services are covered under the Medicaid state plan. Section 1902(a)(43) of the Act requires that the State (1) provide and arrange for all necessary services, including supportive services, such as transportation, needed to receive medical care included within the scope of the EPSDT benefit and (2) inform eligible beneficiaries about the services available under the EPSDT benefit.

If the coverage provided does not meet all of the statutory requirements for EPSDT contained in sections 1902(a)(43) and 1905(r) of the Act, do not check this box.

6.1.4.1. X Coverage of all benefits that are provided to children that is the same as the benefits provided under the Medicaid State plan, including Early Periodic Screening, Diagnostic, and Treatment (EPSDT). This applies to mothers covered under the unborn child group who are under age 21.

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver.

6.1.4.3. X Coverage that the State has extended to the entire Medicaid population. For mothers under age 21, benefits related to pregnancy, full Medicaid benefits and EPSDT; for mothers age 21 and older, benefits related to pregnancy in addition to full Medicaid benefits for adults. Guidance: Check below if the coverage offered includes benchmark coverage, as specified in §457.420, plus additional coverage. Under this option, the State must clearly demonstrate that the coverage it provides includes the same coverage as the benchmark package, and also describes the services that are being added to the benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage.

6.1.4.5.

Coverage that is the same as defined by existing comprehensive state- based coverage applicable only in New York, Pennsylvania or Florida. (under 42 CFR 457.440)

Guidance: Check below if the State is purchasing coverage through a group health plan, and intends to demonstrate that the group health plan is substantially equivalent to or greater than coverage under one of the benchmark plans specified in 457.420, through the use of a benefit-by-benefit comparison

11 of the coverage. Provide a sample of the comparison format that will be used. Under this option, if coverage for any benefit does not meet or exceed the coverage for that benefit under the benchmark, the State must provide an actuarial analysis as described in 457.431 to determine actuarial equivalence.

6.1.4.6.

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

Guidance: Check below if the State elects to provide a source of coverage that is not described above. Describe the coverage that will be offered, including any benefit limitations or exclusions.

6.1.4.7.

Other. (Describe)

Guidance: All forms of coverage that the State elects to provide to children in its plan must be checked. The State should also describe the scope, amount and duration of services covered under its plan, as well as any exclusions or limitations. States that choose to cover unborn children under the State plan should include a separate section 6.2 that specifies benefits for the unborn child population. (Section 2110(a)) (42 CFR, 457.490)

If the state elects to cover the new option of targeted low income pregnant women, but chooses to provide a different benefit package for these pregnant women under the CHIP plan, the state must include a separate section 6.2 describing the benefit package for pregnant women. (Section 2112)

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

6.2.1. X

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

6.2.2. X

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

6.2.3. X

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

6.2.4. X

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

6.2.5. X

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

6.2.6. X

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

12

6.2.7. X

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

6.2.8. X

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

6.2.9. X

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

6.2.10. X

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

6.2.11. X

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

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

6.2.13. X Disposable medical supplies (Section 2110(a)(13))

Guidance: Home and community based services may include supportive services such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home.

6.2.14.

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

Guidance: Nursing services may include nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services in a home, school or other setting.

6.2.15. X

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

6.2.16. X

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

6.2.17. X

Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)

Limits apply to individuals 21 and older:

13 6.2.18. X

Vision screenings and services (Section 2110(a)(24))

6.2.19. X

Hearing screenings and services (Section 2110(a)(24))

6.2.20. X

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

6.2.21. X

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

6.2.22. X

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

6.2.23. X

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

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

6.2.25. X Hospice care (Section 2110(a)(23))

Guidance: See guidance for Section 6.1.4.1 for guidance on the statutory requirements for EPSDT under sections 1905(r) and 1902(a)(43) of the Act. If the benefit being provided does not meet the EPSDT statutory requirements, do not check the box below.

6.2.26. X EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act, applicable to mothers in the unborn child group who are under age 21.

Guidance: Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic or rehabilitative service may be provided, whether in a facility, home, school, or other setting, if recognized by State law and only if the service is: 1) prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as prescribed by State law; 2) performed under the general supervision or at the direction of a physician; or 3) furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.

6.2.27. X

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

6.2.28.

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

6.2.29. X Medical transportation (Section 2110(a)(26))

14 Guidance: Enabling services, such as transportation, translation, and outreach services, may be offered only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.

6.2.30. X Enabling services (such as transportation, translation, and outreach services) (Section 2110(a)(27))

6.2.31. X Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28)) Home health care, personal care assistance service, ambulance, freestanding birth centers, integrated health partnerships

6.2-DC Dental Coverage (CHIPRA # 7, SHO # #09-012 issued October 7, 2009) The State will provide dental coverage to children through one of the following. Please update Sections 9.10 and 10.3-DC when electing this option. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5)):

6.2.1-DC State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT1) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999) 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached)

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

15

6.2.2-DC Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1-DC FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental supplemental plan benefits description and the applicable CDT2 codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2.2.2-DC State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2.2.3-DC HMO with largest insured commercial enrollment (Section 2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, also attach a description of the services and applicable CDT codes)

6.2-DS

Supplemental Dental Coverage- The State will provide dental coverage to children eligible for dental-only supplemental services. Children eligible for this option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2110(b)(5)(C)(ii)). Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, and 9.10 when electing this option.

Guidance: Under Title XXI, pre-existing condition exclusions are not allowed, with the only exception being in relation to another law in existence (HIPAA/ERISA). Indicate that the plan adheres to this requirement by checking the applicable description.

In the event that the State provides benefits through a group health plan or group health coverage, or provides family coverage through a group health plan under a waiver (see Section 6.4.2.), pre-existing condition limits are allowed to the extent permitted by HIPAA/ERISA. If the State is contracting with a group health plan or provides benefits through group health coverage, describe briefly any limitations on pre-existing conditions. (Formerly 8.6.)

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State

Current Dental Terminology, © 2010 American Dental Association. All rights reserved.

16 child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) X Other Describe: federal and state law definitions which designate a service as MH, SUD or Med /Surgical) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

X Yes No Guidance: If the State does not provide any mental health or substance use disorder benefits, the mental health parity requirements do not apply ((42 CFR 457.496(f)(1)). Continue on to Section 6.3.

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section

17 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

X Yes No Guidance: If the State child health plan does not provide EPSDT consistent with Medicaid statutory requirements at sections 1902(a)(43) and 1905(r) of the Act, please go to Section 6.2.3- MHPAEA to complete the required parity analysis of the State child health plan.

If the state does provide EPSDT benefits consistent with Medicaid requirements, please continue this section to demonstrate compliance with the statutory requirements of section 2103(c)(6)(B) of the Act and the mental health parity regulations of 42 CFR 457.496(b) related to deemed compliance. Please provide supporting documentation, such as contract language, provider manuals, and/or member handbooks describing the state’s provision of EPSDT.

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan. X A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements. Mothers of unborn children who are under age 21 receive EPSDT in their benefit set. [MCO Model contract provisions for EPSDT attached.] Mothers of unborn children age 21 and older do not receive EPSDT services. Guidance: If only a subset of children are provided EPSDT benefits under the State child health plan, 42 CFR 457.496(b)(3) limits deemed compliance to those children only and Section 6.2.3- MHPAEA must be completed as well as the required parity analysis for the other children.

18 6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

X All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

X All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

X All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

X Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

X Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

X EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

19 X The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

X All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT, the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3- MHPAEA.

Mental Health Parity Analysis Requirements for States Not Providing EPSDT to All Covered Populations

Guidance: The State must complete a parity analysis for each population under the State child health plan that is not provided the EPSDT benefit consistent with the requirements 42 CFR 457.496(b). If the State provides benefits or limitations that vary within the child or pregnant woman populations, states should perform a parity analysis for each of the benefit packages. For example, if different financial requirements are applied according to a beneficiary’s income, a separate parity analysis is needed for the benefit package provided at each income level.

Please ensure that changes made to benefit limitations under the State child health plan as a result of the parity analysis are also made in Section 6.2.

6.2.3- MHPAEA In order to conduct the parity analysis, the State must place all medical/surgical and mental health and substance use disorder benefits covered under the State child health plan into one of four classifications: Inpatient, outpatient, emergency care, and prescription drugs. (42 CFR 457.496(d)(2)(ii); 42 CFR 457.496(d)(3)(ii)(B))

This section applies to mothers of unborn children in the separate CHIP Plan who are age 21 and older. 6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications.

6.2.3.1.1 MHPAEA The State assures that:

X The State has classified all benefits covered under the State plan into one of the four classifications.

20 X The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. As part of the parity analysis, the Department placed the Medicaid benefits into one of four classifications using consistent definitions across mental health/substance abuse disorder and medical/surgical services. The Department used the following standards when determining which benefit category to place a benefit: • Inpatient: Covered services provided to a beneficiary while the beneficiary is considered a resident of an inpatient or residential facility for a period greater than 24 hours. • Outpatient: Covered services provided to a beneficiary in an ambulatory or community setting, which is not considered emergency care, for a period less than 24 hours per episode of care. • Prescription Drugs: Covered medications, drugs and associated supplies requiring a prescription, and provided by a qualified provider. • Emergency Care: Covered services provided to a beneficiary in order to stabilize an emergency/crisis condition. Services may be provided in an emergency department or other setting.

6.2.3.1.2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes X No

6.2.3.1.2.1- MHPAEA If the State uses sub-classifications to distinguish between outpatient office visits and other outpatient services, the State assures the following:

The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits).

21 Guidance: For purposes of this section, any reference to “classification(s)” includes sub-classification(s) in states using sub- classifications to distinguish between outpatient office visits from other outpatient services.

6.2.3.2 MHPAEA The State assures that:

X Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan. Guidance: States are not required to cover mental health or substance use disorder benefits (42 CFR 457.496(f)(2)). However if a state does provide any mental health or substance use disorder benefits, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan (42 CFR 457.496(d)(2)(ii).

Annual and Aggregate Lifetime Dollar Limits

6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan.

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied X No dollar limit is applied Guidance: A monetary coverage limit that applies to all CHIP services provided under the State child health plan is not subject to parity requirements.

If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

22 Yes (Type(s) of limit: ) X No Guidance: If no aggregate lifetime dollar limit is applied to medical/ surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits. (42 CFR 457.496(c)(1))

6.2.4.3 – MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one- third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)). The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. Guidance: Please include the state’s methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as an attachment to the State child health plan.

6.2.4.3.1- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

6.2.4.3.2- MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit:

Less than 1/3

23 At least 1/3 and less than 2/3 At least 2/3 Guidance: If an aggregate lifetime limit is applied to less than one-third of all medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (42 CFR 457.496(c)(1)). Skip to section 6.2.5- MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one-third of all medical/surgical benefits, please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either an annual or lifetime limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least 1/3 and less than 2/3 of all medical/surgical benefits, the State assures the following (42 CFR 457.496(c)(4)(i)(B)); (42 CFR 457.496(c)(4)(ii)):

The State applies an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no more restrictive than an average limit calculated for medical/surgical benefits. Guidance: The state’s methodology for calculating the average limit for medical/surgical benefits must be consistent with 42 CFR 457.496(c)(4)(i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)):

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or

24 The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits. Quantitative Treatment Limitations

6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes X No Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6 - MHPAEA. If the state does apply QTLs to any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes X No Guidance: If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use disorder benefits, please go to Section 6.2.6- MHPAEA related to non- quantitative treatment limitations.

6.2.5.2- MHPAEA Within each classification of benefits in which the State applies a type of QTL on any mental health or substance use disorder benefits, the State must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan

25 includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.5.3- MHPAEA For each type of QTL applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of QTL to “substantially all” (defined as at least two-thirds) of the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of QTL to substantially all medical/surgical benefits in a given classification of benefits, the State may not impose that type of QTL on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

6.2.5.3.1- MHPAEA For each type of QTL applied to mental health or substance use disorder benefits, the State must determine the predominant level of that type which is applied to medical/surgical benefits in the classification. The “predominant level” of a type of QTL in a classification is the level (or least restrictive of a combination of levels) that applies to more than one-half of the medical/surgical benefits in that classification, as described in 42 CFR 457.496(d)(3)(i)(B). The portion of medical/surgical benefits in a classification to which a given level of a QTL type is applied is based on the dollar amount of payments expected to be paid for medical/surgical benefits subject to that level as compared to all medical/surgical benefits in the classification, as described in 42 CFR 457.496(d)(3)(i)(C). For each type of quantitative treatment limitation applied to mental health or substance use disorder benefits, the State assures:

The same reasonable methodology applied in determining the dollar amounts used to determine whether substantially all medical/surgical benefits within a classification are subject to a type of quantitative treatment limitation also is applied in determining the dollar amounts used to determine the predominant

26 level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of QTL that exceeds the one- half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4)); (42 CFR 457.496(d)(5)) 6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

X The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification. Guidance: Examples of NQTLs include medical management standards to limit or exclude benefits based on medical necessity, restrictions based on geographic location, provider specialty, or other criteria to limit the scope or duration of benefits and provider network design (ex: preferred providers vs. participating providers). Additional examples of possible NQTLs are provided in 42 CFR 457.496(d)(4)(ii). States will need to provide a summary of its NQTL analysis, as well as supporting documentation as requested.

See Attachment C.

6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if

27 they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide

coverage of medical or surgical benefits provided by out-of-network providers?

X Yes No Guidance: The State can answer no if the State or MCE only provides out of network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

6.2.6.2.2- MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following:

X The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information 6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State X Managed Care entities Both Other

Guidance: If other is selected, please specify the entity.

28

6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for

mental health or substance use disorder benefits must be made available to the

enrollee by the health plan or the State. The state attests that the following

entities provide denial information:

State X Managed Care entities Both

Other

Guidance: If other is selected, please specify the entity. 6.3. The State assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42 CFR 457.480)

6.3.1. X

The State shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The State contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.6.2. (formerly 6.4.2) of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA. (Formerly 8.6.) (Section 2103(f)) Describe:

Guidance: States may request two additional purchase options in Title XXI: cost effective coverage through a community-based health delivery system and for the purchase of family coverage. (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

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

6.4.1.

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

29

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

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

Guidance: Check below if the State is requesting to provide cost-effective coverage through a community-based health delivery system. This allows the State to waive the 10 percent limitation on expenditures not used for Medicaid or health insurance assistance if coverage provided to targeted low-income children through such expenditures meets the requirements of Section 2103; the cost of such coverage is not greater, on an average per child basis, than the cost of coverage that would otherwise be provided under Section 2103; and such coverage is provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under Section 330 of the Public Health Services Act or with hospitals such as those that receive disproportionate share payment adjustments under Section 1886(c)(5)(F) or 1923.

If the cost-effective alternative waiver is requested, the State must demonstrate that payments in excess of the 10 percent limitation will be used for other child health assistance for targeted low-income children; expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); expenditures for outreach activities as provided in Section 2102(c)(1) under the plan; and other reasonable costs incurred by the State to administer the plan. (42 CFR, 457.1005(a))

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

30 Guidance: Check 6.4.2.if the State is requesting to purchase family coverage. Any State requesting to purchase such coverage will need to include information that establishes to the Secretary’s satisfaction that: 1) when compared to the amount of money that would have been paid to cover only the children involved with a comparable package, the purchase of family coverage is cost effective; and 2) the purchase of family coverage is not a substitution for coverage already being provided to the child. (Section 2105(c)(3)) (42 CFR 457.1010)

6.4.2.

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

6.4.2.1. Purchase of family coverage is cost-effective. The State’s cost of purchasing family coverage, including administrative expenditures, that includes coverage for the targeted low-income children involved or the family involved (as applicable) under premium assistance programs must not be greater than the cost of obtaining coverage under the State plan for all eligible targeted low-income children or families involved; and (2) The State may base its demonstration of cost effectiveness on an assessment of the cost of coverage, including administrative costs, for children or families under premium assistance programs to the cost of other CHIP coverage for these children or families, done on a case-by-case basis, or on the cost of premium assisted coverage in the aggregate.

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

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

6.4.3-PA: Additional State Options for Providing Premium Assistance (CHIPRA # 13, SHO # 10-002 issued February, 2, 2010) A State may elect to offer a premium assistance subsidy for qualified employer-sponsored coverage, as defined in Section 2105(c)(10)(B), to all targeted low-income children who are eligible for child health assistance under the plan and have access to such coverage. No subsidy shall be provided to a targeted low-income child (or the child’s parent) unless the child voluntarily elects to receive such a subsidy. (Section 2105(c)(10)(A)). Please remember to update section 9.10 when electing this option. Does the State provide this option to targeted low-income children?

31

Yes X

No

6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance Subsidy

6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored insurance meets the definition of qualified employer-sponsored coverage as defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(C).

6.4.3.1.2-PA Describe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee’s employer.

6.4.3.2-PA: Supplemental Coverage for Benefits and Cost Sharing Protections Provided under the Child Health Plan.

6.4.3.2.1-PA If the State is providing premium assistance for qualified employer- sponsored coverage, as defined in Section 2105(c)(10)(E)(i), provide an assurance that the State is providing for each targeted low-income child enrolled in such coverage, supplemental coverage consisting of all items or services that are not covered or are only partially covered, under the qualified employer-sponsored coverage consistent with 2103(a) and cost sharing protections consistent with Section 2103(e).

6.4.3.2.2-PA Describe whether these benefits are being provided through the employer or by the State providing wraparound benefits.

6.4.3.2.3-PA If the State is providing premium assistance for benchmark or benchmark-equivalent coverage, the State ensures that such group health plans or health insurance coverage offered through an employer will be certified by an actuary as coverage that is equivalent to a benchmark benefit package described in Section 2103(b) or benchmark equivalent coverage that meets the requirements of Section 2103(a)(2).

6.4.3.3-PA: Application of Waiting Period Imposed Under State Plan: States are required to apply the same waiting period to premium assistance as is applied to direct coverage for children under their CHIP State plan, as specified in Section 2105(c)(10)(F).

32 6.4.3.3.1-PA Provide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State has a waiting period in place for children in direct CHIP coverage).

6.4.3.4-PA: Opt-Out and Outreach, Education, and Enrollment Assistance

6.4.3.4.1-PA Describe the State’s process for ensuring parents are permitted to disenroll their child from qualified employer-sponsored coverage and to enroll in CHIP effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child (Section 2105(c)(10)(G)).

6.4.3.4.2-PA Describe the State’s outreach, education, and enrollment efforts related to premium assistance programs, as required under Section 2102(c)(3). How does the State inform families of the availability of premium assistance, and assist them in obtaining such subsidies? What are the specific significant resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan? (Section 2102(c))

6.4.3.5-PA Purchasing Pool- A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool (Section 2105(c)(10)(I)). Does the State provide this option?

Yes

No

6.6.3.5.1-PA Describe the plan to establish an employer-family premium assistance purchasing pool.

6.6.3.5.2-PA Provide an assurance that employers who are eligible to participate: 1) have less than 250 employees; 2) have at least one employee who is a pregnant woman eligible for CHIP or a member of a family that has at least one child eligible under the State’s CHIP plan.

6.6.3.5.3-PA Provide an assurance that the State will not claim for any administrative expenditures attributable to the establishment or operation of such a pool except to the extent such payment would otherwise be permitted under this title.

6.4.3.6-PA Notice of Availability of Premium Assistance- Describe the procedures that assure that if a State provides premium assistance subsidies under this Section, it must: 1) provide as part of the application and enrollment

33 process, information describing the availability of premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to ensure that parents are fully informed of the choices for child health assistance or through the receipt of premium assistance subsidies (Section 2105(c)(10)(K)).

6.4.3.6.1-PA Provide an assurance that the State includes information about premium assistance on the CHIP application or enrollment form.

GLOSSARY Adapted directly from Sec. 2110. DEFINITIONS. CHILD HEALTH ASSISTANCE- For purposes of this title, the term ‘child health assistance’ means payment for part or all of the cost of health benefits coverage for targeted low-income children that includes any of the following (and includes, in the case described in Section 2105(a)(2)(A), payment for part or all of the cost of providing any of the following), as specified under the State plan: 1. Inpatient hospital services. 2. Outpatient hospital services. 3. Physician services. 4. Surgical services. 5. Clinic services (including health center services) and other ambulatory health care services. 6. Prescription drugs and biologicals and the administration of such drugs and biologicals, only if such drugs and biologicals are not furnished for the purpose of causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a person. 7. Over-the-counter medications. 8. Laboratory and radiological services. 9. Prenatal care and prepregnancy family planning services and supplies.

34 10. Inpatient mental health services, other than services described in paragraph (18) but including services furnished in a State-operated mental hospital and including residential or other 24-hour therapeutically planned structured services. 11. Outpatient mental health services, other than services described in paragraph (19) but including services furnished in a State-operated mental hospital and including community-based services. 12. Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices). 13. Disposable medical supplies. 14. Home and community-based health care services and related supportive services (such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home). 15. Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services) in a home, school, or other setting. 16. Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. 17. Dental services. 18. Inpatient substance abuse treatment services and residential substance abuse treatment services. 19. Outpatient substance abuse treatment services. 20. Case management services. 21. Care coordination services. 22. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders. 23. Hospice care. 24. Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (whether in a facility, home, school, or other setting) if recognized by State law and only if the service is-- a. prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by State law, b. performed under the general supervision or at the direction of a physician, or c. furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license. 25. Premiums for private health care insurance coverage. 26. Medical transportation. 27. Enabling services (such as transportation, translation, and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals. 28. Any other health care services or items specified by the Secretary and not excluded under this section.

TARGETED LOW-INCOME CHILD DEFINED- For purposes of this title--

35 1. IN GENERAL- Subject to paragraph (2), the term ‘targeted low-income child’ means a child-- a. who has been determined eligible by the State for child health assistance under the State plan; b. (i) who is a low-income child, or (ii) is a child whose family income (as determined under the State child health plan) exceeds the Medicaid applicable income level (as defined in paragraph (4)), but does not exceed 50 percentage points above the Medicaid applicable income level; and c. who is not found to be eligible for medical assistance under title XIX or covered under a group health plan or under health insurance coverage (as such terms are defined in Section 2791 of the Public Health Service Act). 2. CHILDREN EXCLUDED- Such term does not include-- a. a child who is a resident of a public institution or a patient in an institution for mental diseases; or b. a child who is a member of a family that is eligible for health benefits coverage under a State health benefits plan on the basis of a family member's employment with a public agency in the State. 3. SPECIAL RULE- A child shall not be considered to be described in paragraph (1)(C) notwithstanding that the child is covered under a health insurance coverage program that has been in operation since before July 1, 1997, and that is offered by a State which receives no Federal funds for the program's operation. 4. MEDICAID APPLICABLE INCOME LEVEL- The term ‘Medicaid applicable income level’ means, with respect to a child, the effective income level (expressed as a percent of the poverty line) that has been specified under the State plan under title XIX (including under a waiver authorized by the Secretary or under Section 1902(r)(2)), as of June 1, 1997, for the child to be eligible for medical assistance under Section 1902(l)(2) for the age of such child. 5. TARGETED LOW-INCOME PREGNANT WOMAN.—The term ‘targeted low-income pregnant woman’ means an individual— (A) during pregnancy and through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends; (B) whose family income exceeds 185 percent (or, if higher, the percent applied under subsection (b)(1)(A)) of the poverty line applicable to a family of the size involved, but does not exceed the income eligibility level established under the State child health plan under this title for a targeted low-income child; and (C) who satisfies the requirements of paragraphs (1)(A), (1)(C), (2), and (3) of Section 2110(b) in the same manner as a child applying for child health assistance would have to satisfy such requirements.

ADDITIONAL DEFINITIONS- For purposes of this title: 1. CHILD- The term ‘child’ means an individual under 19 years of age. 2. CREDITABLE HEALTH COVERAGE- The term ‘creditable health coverage’ has the meaning given the term ‘creditable coverage’ under Section 2701(c) of the Public Health Service Act (42 U.S.C. 300gg(c)) and includes coverage that meets the requirements of section 2103 provided to a targeted low-income child under this title or under a waiver approved under section 2105(c)(2)(B) (relating to a direct service waiver). 3. GROUP HEALTH PLAN; HEALTH INSURANCE COVERAGE; ETC- The terms ‘group

36 health plan’, ‘group health insurance coverage’, and ‘health insurance coverage’ have the meanings given such terms in Section 2191 of the Public Health Service Act. 4. LOW-INCOME CHILD - The term ‘low-income child’ means a child whose family income is at or below 200 percent of the poverty line for a family of the size involved. 5. POVERTY LINE DEFINED- The term ‘poverty line’ has the meaning given such term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section. 6. PREEXISTING CONDITION EXCLUSION- The term ‘preexisting condition exclusion’ has the meaning given such term in section 2701(b)(1)(A) of the Public Health Service Act (42 U.S.C. 300gg(b)(1)(A)). 7. STATE CHILD HEALTH PLAN; PLAN- Unless the context otherwise requires, the terms ‘State child health plan’ and ‘plan’ mean a State child health plan approved under Section 2106. 8. UNINSURED CHILD- The term ‘uninsured child’ means a child that does not have creditable health coverage.

_____________________________________________________________________________ Table of Contents State/Territory Name: Minnesota State Plan Amendments (SPA) #: MN-18-0013-CHIP This file contains the following documents in the order listed: 1) Approval Letter 2) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Children and Adulfs Health Prosrams Groun crvts ctNnRs f oR MtDt(áßÊ & Mtu¡t¡tD stRvtcts CENTER FON MEOICAID & CHIP SERVICTS JAN I 7 2019 Ms. Ann Berg Deputy Medicaid Director Minnesota Department of Human Services 540 Cedar Street St. Paul, Minnesota 55101 Dear Ms. Berg: I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA), MN-l8-0013-CHIP, has been approved. MN-18-0013-CHIP demonstrates compliance with the CHIP managed care regulations at 42 CFR 457 Subpart L for utilization of a managed care delivery system. This SPA has an effective date of July l, 2018. Sections 2l0l(a),2103(Ð(3), 2l0l(b), and2107(e) of the Social Security Act, as implemented through regulations at 42 CFR 457 Subpart L, describe the application of managed care requirements to CHIP. Minnesota has provided the necessary assurances indicating that the state complies with the managed care requirements in the delivery of CHIP services and benefits covered under the state's separate child health plan as of July l, 2018, with the following exceptions: o Effective October 1,2018, the state came into compliance with beneficiary protections for service costs described in section 3.8.2 of the state plan (42 CFR 457.I20I(p)), and provider screening and enrollment requirements in section 3.10.7 of the state plan (42 cFR 457.1285); . Effective December 31,2018, the state came into compliance with requirements pertaining to the posting of managed care entities' accreditation status on a V/eb site in section 3.12.3.2 of the state plan, (42 CFR 457 .1240(c)); and . Effective January 1,2019, the state came into compliance with the requirement that information regarding the certification and audits of managed care entities be publicly available on a Web site as described in section 3. I 0. I 6 of the state plan (42 CFR 4s7.r28s). This SPA approval does not substitute for CMS review of any contracts between the state and managed care entities that serve the state's CHIP populations. All managed care contracts for CHIP populations in effect as of the state hscal year beginning on or after July l, 2018 must comply with the CHIP managed care regulations and be submitted for CMS review.

Page 2 - Ms. Ann Berg Your title XXI project officer is Ms. Michelle Wojcicki. She is available to answer questions concerning this amendment and other CHIP-related issues. Her contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop: S2-0l-16 Baltimore, MD 21244-1850 Telephone: ( 410) 786-0306 E-mail: michelle.wojcickil@cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Ms. Wojcicki and to Ms. Ruth Hughes, Associate Regional Administrator (ARA) in our Chicago Regional Office. Ms. Hughes' address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations 233 North Michigan Avenue, Suite 600 Chicago, IL 60601 We look forward to continuing to work with you and your staff. ''"=ly,

eCoo"'11, Director cc: Ms. Ruth Hughes, ARA, CMS Region V, Chicago /signed Anne Marie Costello/

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

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

State/Territory: MINNESOTA

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

Signature of Ann Berg, Deputy Medicaid Director Date: 11/27/2018

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

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

Name: Julie Marquardt

Position/Title: Director, Purchasing and Service Delivery & Health Name: Nathan Moracco Position/Title: Assistant Commissioner, Health Care Administration

Name: Alexandra Kotze

Position/Title: Chief Financial Officer, DHS

*Disclosure. In accordance with 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 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010, further modified the program. The HEALTHY KIDS Act and The Bipartisan Budget Act of 2018 together resulted in an extension of funding for CHIP through

2 federal fiscal year 2027.

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

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

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

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

4 limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below:

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

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

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

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the

6 State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

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

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

7 Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

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

Original Plan Effective Date: 09/30/1998

Implementation Date: 09/30/1998

SPA #13 Purpose of SPA: Managed care compliance Proposed effective date: 07/01/2018

Proposed implementation date: 07/01/2018

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

Minnesota tribes were notified of this proposed amendment on August 22, 2018. No comments were received.

Transmittal Number: 13

Approval Date:

Effective Date: July 1, 2018

8 Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4 (Eligibility Standards and Methodology).

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

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

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. X Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee- for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2.

9 Guidance: Utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package. Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b)) If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of: • The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b))

Guidance: Only States that use a managed care delivery system for all or some CHIP populations need to answer the remaining questions under Section 3 (starting with 3.1.1.2). If the State uses a managed care delivery system for only some of its CHIP population, the State’s responses to the following questions will only apply to those populations. 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system? No X Yes

If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee,

10 such as through fee-for-service. Examples of carved out services may include transportation and dental, among others. Child welfare targeted case management; targeted case managed services for vulnerable adults, adults with developmental disabilities or related conditions, or adults without a permanent residence; services under an individualized education or family service plan; nursing facility services.

3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use: X Managed care organization (MCO) (42 CFR 457.10) X Capitation payment

Describe population served: unborn children

Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Guidance: If the State uses prepaid ambulatory health plan(s) (PAHP) to exclusively provide non-emergency medical transportation (a NEMT PAHP), the State should not check the following box for that plan. Instead, complete section 3.1.3 for the NEMT PAHP. Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain)

11 Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

3.1.2.2 X The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i)) 3.1.3 Nonemergency Medical Transportation PAHPs Guidance: Only complete Section 3.1.3 if the State uses a PAHP to exclusively provide non- emergency medical transportation (a NEMT PAHP). If a NEMT PAHP is the only managed care entity for CHIP in the State, please continue to Section 4 after checking the assurance below. If the State uses a PAHP that does not exclusively provide NEMT and/or uses other managed care entities beyond a NEMT PAHP, the State will need to complete the remaining sections within Section 3.

12

The State assures that it complies with all requirements applicable to NEMT PAHPs, and through its contracts with such entities, requires NEMT PAHPs to comply with all applicable requirements, including the following (from 42 CFR 457.1206(b)): • All contract provisions in 42 CFR 457.1201 except those set forth in 42 CFR 457.1201(h) (related to physician incentive plans) and 42 CFR 457.1201(l) (related to mental health parity). • The information requirements in 42 CFR 457.1207 (see Section 3.5 below for more details). • The provision against provider discrimination in 42 CFR 457.1208. • The State responsibility provisions in 42 CFR 457.1212 (about disenrollment), 42 CFR 457.1214 (about conflict of interest safeguards), and 42 CFR 438.62(a), as cross-referenced in 42 CFR 457.1216 (about continued services to enrollees). • The provisions on enrollee rights and protections in 42 CFR 457.1220, 457.1222, 457.1224, and 457.1226. • The PAHP standards in 42 CFR 438.206(b)(1), as cross-referenced by 42 CFR 457.1230(a) (about availability of services), 42 CFR 457.1230(d) (about coverage and authorization of services), and 42 CFR 457.1233(a), (b) and (d) (about structure and operation standards). • An enrollee's right to a State review under subpart K of 42 CFR 457. • Prohibitions against affiliations with individuals debarred or excluded by Federal agencies in 42 CFR 438.610, as cross referenced by 42 CFR 457.1285. • Requirements relating to contracts involving Indians, Indian Health Care Providers, and Indian managed care entities in 42 CFR 457.1209.

3.2. General Managed Care Contract Provisions

3.2.1 X The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2 X The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c)) 3.2.3 X The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect

13 those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4 X The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3)) 3.3 Rate Development Standards and Medical Loss Ratio 3.3.1 The State assures that its payment rates are: X Based on public or private payment rates for comparable services for comparable populations; and X Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a))

Guidance: States that checked both boxes under 3.3.1 above do not need to make the next assurance. If the state is unable to check both boxes under 3.1.1 above, the state must check the next assurance. If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2 X The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3 X The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4 X The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a))

14 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1)) No, the State does not require any MCO, PIHP, or PAHP to pay remittances. X Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittances but not a dental PAHP, please include this information. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance: X The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State: • Reimburses CMS for an amount equal to the Federal share of the remittance, taking into account applicable differences in the Federal matching rate; and • Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b))

3.3.6 X The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment X The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity: • Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1)); • Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(3)); and • Will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use

15 any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-referencing to 438.3(d)(4)) 3.4.1 Enrollment Process 3.4.1.1 X The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c)) 3.4.1.2 X The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)) X Yes No

If the State uses a default enrollment process, please make the following assurances: X The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)) X The State maximizes continuation of existing provider-beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment

16 3.4.2.1 X The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)) 3.4.2.2 X The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross-referencing to 438.56(e)(1)) 3.4.2.3 X If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212, cross referencing to 42 CFR 438.56; State Health Official Letter #09-008) 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. X The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)) Guidance: Reasons for disenrollment by the MCO, PIHP, PAHP, PCCM, and PCCM entity must be specified in the contract with the State. Reasons for disenrollment may not include an adverse change in the enrollee's health status, or because of the enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment in the MCO, PIHP, PAHP, PCCM or PCCM entity seriously impairs the entity's ability to furnish services to either this particular enrollee or other enrollees). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(b)(2)) 3.4.2.5 Enrollee Requests for Disenrollment. Guidance: The State may also choose to limit disenrollment from the MCO, PIHP, PAHP, PCCM, or PCCM entity, except for either: 1) for cause, at any time; or 2) without cause during the latter of the 90 days after the

17 beneficiary’s initial enrollment or the State sends the beneficiary notice of that enrollment, at least once every 12 months, upon reenrollment if the temporary loss of CHIP eligibility caused the beneficiary to miss the annual disenrollment opportunity, or when the State imposes the intermediate sanction specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) X Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)): X The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1)) X The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2)) X The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: • During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later; • At least once every 12 months thereafter; • If the State plan provides for automatic reenrollment for an individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and • When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6 X The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2))

18 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1 X The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees and potential enrollees in accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10. 3.5.2 X The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(c)(1)) 3.5.3 X The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites. 3.5.4 X The State assures that it has developed and requires each MCO, PIHP, PAHP and PCCM entity to use: • Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and • Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(4))

3.5.5 X If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that: • The format is readily accessible; • The information is placed in a location on the State, MCO's, PIHP's, PAHP's, or PCCM's, or PCCM entity's Web site that is prominent and readily accessible; • The information is provided in an electronic form which can be electronically retained and printed; • The information is consistent with the content and language requirements in 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days.

19 3.5.6 X The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to: • Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area; • Making oral interpretation available in all languages and written translation available in each prevalent non-English language; • Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent non- English languages in its particular service area; • Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP, and PCCM entity to make those services available free of charge to each enrollee; and • Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7 X The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities: • Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance; • The basic features of managed care; • Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the program; • The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity; • Covered benefits including: o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if

20 any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to obtain the service; • The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i); • Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State plan; • The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68; • The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and • To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. 3.5.8 X The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. 3.5.9 X The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that: • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i).

3.5.10 X The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items: • Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include:

21 o Benefits provided by the MCO, PIHP, PAHP or PCCM entity; o How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and o In the case of a counseling or referral service that the MCO, PIHP, PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO, PIHP, PAHP, or PCCM entity must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from the State about how to access these services; • The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled; • Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider; • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition and emergency services; o The fact that prior authorization is not required for emergency services; and o The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care; • Any restrictions on the enrollee's freedom of choice among network providers; • The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of-network providers; • Cost sharing, if any is imposed under the State plan; • Enrollee rights and responsibilities, including the elements specified in 42 CFR §438.100; • The process of selecting and changing the enrollee's primary care provider; • Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State-approved description, including: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; and o The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; • How to access auxiliary aids and services, including additional

22 information in alternative formats or languages; • The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and • Information on how to report suspected fraud or abuse. 3.5.11 X The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days before the intended effective date of the change. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(4)) 3.5.12 X The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(1)-(2) and (4). 3.5.13 X The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directories as specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3)) 3.5.14 X The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross- referencing to 42 CFR 438.10(i), including: • Which medications are covered (both generic and name brand); and • What tier each medication is on. 3.5.15 X The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross- referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)). Guidance: Requirements for marketing activities include, but are not limited to, that the MCO, PIHP, PAHP, PCCM, or PCCM entity does not distribute any marketing materials without first obtaining State approval; distributes the materials to its entire service areas as indicated in the contract; does not seek to influence enrollment in conjunction with the sale or offering of any private insurance; and does not, directly or indirectly, engage in door-to-door, telephone, email, texting, or other cold-call marketing activities. (42 CFR 104(b))

23 Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.5 (3.5.16 through 3.5.18). 3.5.16 X The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102. 3.5.17 X The State assures that MCOs, PIHPs, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP, and PAHP from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2)) Guidance: States should also complete Section 3.9, which includes additional provisions about the notice procedures for grievances and appeals. 3.5.18 X The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 457.1260) 3.6 Benefits and Services Guidance: The State should also complete Section 3.10 (Program Integrity). 3.6.1 X The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209) 3.6.2 X The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.3 X The State assures that it: • Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10; • Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross- referencing 42 CFR 438.68(e))

24 Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete the remaining assurances in Section 3.6 (3.6.4 through 3.6.20. 3.6.4 X The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.5 X The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers: • A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities; • Women’s health specialists to provide direct access to covered care necessary to provide women’s routine and preventative health care services for female enrollees; and • Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b) 3.6.6 X The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross-referencing 42 CFR 438.3(l)) 3.6.7 X The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider, or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(3)) 3.6.8 X The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by: • Requiring the contract to adequately and timely cover out-of-network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the network; • Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and services, taking into account the urgency of the need for services; • Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid or CHIP Fee-For-Service, if the provider serves only Medicaid or CHIP enrollees;

25 • Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on a 24 hours a day, 7 days a week basis when medically necessary; • Establishing mechanisms to ensure compliance by network providers; • Monitoring network providers regularly to determine compliance; • Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c)) 3.6.9 X The State assures that each MCO, PIHP, and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross-referencing to 42 CFR 438.207) 3.6.10 X The State assures that each MCO, PIHP, and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated number of enrollees for the service area: • Offers an appropriate range of preventative, primary care and specialty services; and • Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross-referencing to 42 CFR 438.207(b)) 3.6.11 X Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including: • Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP, or PAHP is required to offer; and • Permitting an MCO, PIHP, or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts) 3.6.12 X Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that: • The MCO, PIHP, or PAHP and its subcontractors have in place and follow written policies and procedures; • The MCO, PIHP, or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and

26 • Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii) does not apply to CHIP contracts) 3.6.13 X The State assures that its contracts with each MCO, PIHP, or PAHP require each MCO, PIHP, or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(c)) 3.6.14 X The State assures that its contracts with each MCO, PIHP, or PAHP provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(e)) 3.6.15 X The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP implements the policy. (42 CFR 457.1216, cross-referencing to 42 CFR 438.62) 3.6.16 X The State assures that each MCO, PIHP, and PAHP has implemented procedures to deliver care to and coordinate services for all enrollees in accordance with 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including: • Ensure that each enrollee has an ongoing source of care appropriate to his or her needs; • Ensure that each enrollee has a person or entity formally designated as primarily responsible for coordinating the services accessed by the enrollee; • Provide the enrollee with information on how to contract their designated person or entity responsible for the enrollee’s coordination of services; • Coordinate the services the MCO, PIHP, or PAHP furnishes to the enrollee between settings of care; with services from any other MCO, PIHP, or PAHP; with fee-for-service services; and with the services the enrollee receives from community and social support providers; • Make a best effort to conduct an initial screening of each enrollees needs within 90 days of the effective date of enrollment for all new enrollees;

27 • Share with the State or other MCOs, PIHPs, or PAHPs serving the enrollee the results of any identification and assessment of the enrollee’s needs; • Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards; and • Ensure that each enrollee’s privacy is protected in the process of coordinating care is protected with the requirements of 45 CFR parts 160 and 164 subparts A and E. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(b)) Guidance: For assurances 3.6.17 through 3.6.20, applicability to PIHPs and PAHPs is based a determination by the State in relation to the scope of the entity’s services and on the way the State has organized its delivery of managed care services, whether a particular PIHP or PAHP is required to implement the mechanisms for identifying, assessing, and producing a treatment plan for an individual with special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(a)(2)) 3.6.17 X The State assures that it has implemented mechanisms for identifying to MCOs, PIHPs, and PAHPs enrollees with special health care needs who are eligible for assessment and treatment services under 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy. 3.6.18 X The State assures that each applicable MCO, PIHP, and PAHP implements the mechanisms to comprehensively assess each enrollee identified by the state as having special health care needs. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(2)) 3.6.19 X The State assures that each MCO, PIHP, and PAHP will produce a treatment or service plan that meets the following requirements for enrollees identified with special health care needs: • Is in accordance with applicable State quality assurance and utilization review standards; • Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(3)) 3.6.20 X The State assures that each MCO, PIHP, and PAHP must have a mechanism in place to allow enrollees to directly access a specialist as appropriate for the enrollee's condition and identified needs for enrollees identified with special

28 health care needs who need a course of treatment or regular care monitoring. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(4)) 3.7 Operations 3.7.1 X The State assures that it has established a uniform credentialing and recredentialing policy that addresses acute, primary, behavioral, and substance use disorders providers and requires each MCO, PIHP and PAHP to follow those policies. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(b)(1)) Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the remaining assurances in Section 3.7 (3.7.2 through 3.7.9). 3.7.2 The State assures each contracted MCO, PIHP and PAHP will comply with the provider selection requirements in 42 CFR 457.1208 and 457.1233(a), cross- referencing 42 CFR 438.12 and 438.214, including that: X Each MCO, PIHP, or PAHP implements written policies and procedures for selection and retention of network providers (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(a)); X MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(c)); X MCOs, PIHPs, and PAHPs do not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification, solely on the basis of that license or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); X If an MCO, PIHP, or PAHP declines to include individual or groups of providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP, and PAHP gives the affected providers written notice of the reason for the decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and X MCOs, PIHPs, and PAHPs do not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), cross- referencing 42 CFR 438.214(d)).

3.7.3 The State assures that each contracted MCO, PIHP, and PAHP complies with the subcontractual relationships and delegation requirements in 42 CFR 457.1233(b), cross-referencing 42 CFR 438.230, including that:

29 X The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with the State; X All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor specify that all delegated activities or obligations, and related reporting responsibilities, are specified in the contract or written agreement, the subcontractor agrees to perform the delegated activities and reporting responsibilities specified in compliance with the MCO's, PIHP's, or PAHP's contract obligations, and the contract or written arrangement must either provide for revocation of the delegation of activities or obligations, or specify other remedies in instances where the State or the MCO, PIHP, or PAHP determine that the subcontractor has not performed satisfactorily; X All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor must specify that the subcontractor agrees to comply with all applicable CHIP laws, regulations, including applicable subregulatory guidance and contract provisions; and X The subcontractor agrees to the audit provisions in 438.230(c)(3). 3.7.4 X The State assures that each contracted MCO and, when applicable, each PIHP and PAHP, adopts and disseminates practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field; consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and (c)) 3.7.5 X The State assures that each contracted MCO and, when applicable, each PIHP and PAHP makes decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d)) 3.7.6 X The State assures that each contracted MCO, PIHP, and PAHP maintains a health information system that collects, analyzes, integrates, and reports data consistent with 42 CFR 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.7 X The State assures that it reviews and validates the encounter data collected, maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is a complete and accurate representation of the services provided to the enrollees under the contract between the State and the MCO, PIHP, or PAHP and meets the

30 requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.8 X The State assures that it will submit to CMS all encounter data collected, maintained, submitted to the State by the MCO, PIHP, and PAHP once the State has reviewed and validated the data based on the requirements of 42 CFR 438.242. (CMS State Medicaid Director Letter #13-004) 3.7.9 X The State assures that each contracted MCO, PIHP and PAHP complies with the privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e)) 3.8 Beneficiary Protections 3.8.1 X The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has written policies regarding the enrollee rights specified in 42 CFR 438.100. (42 CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1)) 3.8.2 X The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity will not avoid costs for services covered in its contract by referring enrollees to publicly supported health care resources. (42 CFR 457.1201(p)) This provision was added to the MCO contracts with amendments of 10/2/2018, effective retroactively to 1/1/2018. 3.8.3 X The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable for the following: • The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a)) • Covered services provided to the enrollee for which the State does not pay the MCO, PIHP or PAHP or for which the State, MCO, PIHP, or PAHP does not pay the individual or the health care provider that furnished the services under a contractual, referral or other arrangement. (42 CFR 457.1226, cross- referencing to 42 CFR 438.106(b)) • Payments for covered services furnished under a contract, referral or other arrangement that are in excess of the amount the enrollee would owe if the MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, cross- referencing to 42 CFR 438.106(c)) 3.9 Grievances and Appeals Guidance: Only States with MCOs, PIHPs, or PAHPs need to complete Section 3.9. States with PCCMs and/or PCCM entities should be adhering to the State’s review process for benefits.

31 3.9.1 X The State assures that each MCO, PIHP, and PAHP has a grievance and appeal system in place that allows enrollees to file a grievance and request an appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)) 3.9.2 X The State assures that each MCO, PIHP, and PAHP has only one level of appeal for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b)) 3.9.3 X The State assures that an enrollee may request a State review after receiving notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 438.402(c)) 3.9.4 Does the state offer and arrange for an external medical review? Yes X No

Guidance: Only states that answered yes to assurance 3.9.4 need to complete the next assurance (3.9.5). 3.9.5

The State assures that the external medical review is: • At the enrollee's option and not required before or used as a deterrent to proceeding to the State review; • Independent of both the State and MCO, PIHP, or PAHP; • Offered without any cost to the enrollee; and • Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i)) 3.9.6 X The State assures that an enrollee may file a grievance with the MCO, PIHP, or PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(i)) 3.9.7 X The State assures that an enrollee has 60 calendar days from the date on an adverse benefit determination notice to file a request for an appeal to the MCO, PIHP, or PAHP. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(ii)) 3.9.8 X The State assures that an enrollee may file a grievance and request an appeal either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(3)(i)) 3.9.9 X The State assures that each MCO, PIHP, and PAHP gives enrollees timely and adequate notice of an adverse benefit determination in writing consistent with the requirements below in Section 3.9.10 and in 42 CFR 438.10.

32 3.9.10 X The State assures that the notice of an adverse benefit determination explains: • The adverse benefit determination. • The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits. • The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal and the right to request a State review. • The procedures for exercising the rights specified above under this assurance. • The circumstances under which an appeal process can be expedited and how to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b)) 3.9.11 X The State assures that the notice of an adverse benefit determination is provided in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(c)) 3.9.12 X The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(a)) 3.9.13 The state makes the following assurances related to MCO, PIHP, and PAHP processes for handling enrollee grievances and appeals: X Individuals who make decisions on grievances and appeals were neither involved in any previous level of review or decision-making nor a subordinate of any such individual. X Individuals who make decisions on grievances and appeals, if deciding any of the following, are individuals who have the appropriate clinical expertise in treating the enrollee's condition or disease: • An appeal of a denial that is based on lack of medical necessity. • A grievance regarding denial of expedited resolution of an appeal. • A grievance or appeal that involves clinical issues. X All comments, documents, records, and other information submitted by the enrollee or their representative will be taken into account, without regard to

33 whether such information was submitted or considered in the initial adverse benefit determination. X Enrollees have a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. X Enrollees are provided the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals. X The enrollee and his or her representative or the legal representative of a deceased enrollee's estate are included as parties to the appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(b)) 3.9.14 X The State assures that standard grievances are resolved (including notice to the affected parties) within 90 calendar days from the day the MCO, PIHP, or PAHP receives the grievance. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(b)) Minnesota uses a 30-day time period. 3.9.15 X The State assures that standard appeals are resolved (including notice to the affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal. The MCO, PIHP, or PAHP may extend the timeframe by up to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or PAHP shows that there is need for additional information and that the delay is in the enrollee's interest. (42 CFR 457.1260, cross-referencing to 42 CFR 42 CFR 438.408(b) and (c)) 3.9.16 X The State assures that each MCO, PIHP, and PAHP establishes and maintains an expedited review process for appeals that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal. The expedited review process applies when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a)) 3.9.17 X The State assures that if an MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it transfers the appeal within the timeframe for standard resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, cross- referencing to 42 CFR 438.410(c)(1))

34 3.9.18 X The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an appeal not at the request of the enrollee or it denies a request for an expedited resolution of an appeal, it completes all of the following: • Make reasonable efforts to give the enrollee prompt oral notice of the delay. • Within 2 calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision. • Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(c) and 42 CFR 438.410(c)) 3.9.19 X The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in this section, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State review. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c)(3)) 3.9.20 X The State assures that has established a method that an MCO, PIHP, and PAHP will use to notify an enrollee of the resolution of a grievance and ensure that such methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(1)) 3.9.21 X For all appeals, the State assures that each contracted MCO, PIHP, and PAHP provides written notice of resolution in a format and language that, at a minimum, meet the standards described at 42 CFR 438.10. The notice of resolution includes at least the following items: • The results of the resolution process and the date it was completed; and • For appeals not resolved wholly in favor of the enrollees: o The right to request a State review, and how to do so. o The right to request and receive benefits while the hearing is pending, and how to make the request. o That the enrollee may, consistent with State policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO's, PIHP's, or PAHP's adverse benefit determination. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(i) and (e))

3.9.22 X For notice of an expedited resolution, the State assures that each contracted MCO, PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(ii)) 3.9.23 X The State assures that if it offers an external medical review: • The review is at the enrollee's option and is not required before or used as a

35 deterrent to proceeding to the State review; • The review is independent of both the State and MCO, PIHP, or PAHP; and • The review is offered without any cost to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(f)) 3.9.24 X The State assures that MCOs, PIHPs, and PAHPs do not take punitive action against providers who request an expedited resolution or support an enrollee's appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b)) 3.9.25 X The State assures that MCOs, PIHPs, or PAHPs must provide information specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. This includes: • The right to file grievances and appeals; • The requirements and timeframes for filing a grievance or appeal; • The availability of assistance in the filing process; • The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; and • The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or PAHP seeks to reduce or terminate will continue if the enrollee files an appeal or a request for State review within the timeframes specified for filing, and that the enrollee may, consistent with State policy, be required to pay the cost of services furnished while the appeal or State review is pending if the final decision is adverse to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.414) 3.9.26 X The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records of grievances and appeals and reviews the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the State quality strategy. The record must be accurately maintained in a manner accessible to the state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to 42 CFR 438.416) 3.9.27 X The State assures that if the MCO, PIHP, or PAHP, or the State review officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. (42 CFR 457.1260, cross-referencing to 42 CFR 438.424(a)) 3.10 Program Integrity Guidance: The State should complete Section 11 (Program Integrity) in addition to Section 3.10.

36 Guidance: Only States with MCOs, PIHPs, or PAHPs need to answer the first seven assurances (3.10.1 through 3.10.7). 3.10.1 The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP under a separate child health program has administrative and management arrangements or procedures designed to safeguard against fraud and abuse, including: X Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal and State statutes, regulations, and standards; X Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity; and X Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State, to CMS, or to the Office of Inspector General (OIG) as appropriate, information on violations of law by subcontractors, providers, or enrollees of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

3.10.2 X The State assures that it has in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing 42 CFR 438.58) 3.10.3 X The State assures that it periodically, but no less frequently than once every 3 years, conducts, or contracts for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285, cross referencing 42 CFR 438.602(e)) 3.10.4 X The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors (only to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims) implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following: • A compliance program that include all of the elements described in 42 CFR 438.608(a)(1); • Provision for prompt reporting of all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State; • Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's

37 eligibility; • Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care program, including the termination of the provider agreement with the MCO, PIHP or PAHP; • Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis; • In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers; • Provision for the prompt referral of any potential fraud, waste, or abuse that the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program integrity unit or any potential fraud directly to the State Medicaid Fraud Control Unit; and • Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross referencing 42 CFR 438.608(a)) 3.10.5 X The State assures that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(2)) 3.10.6 X The State assures that each MCO, PIHP, or PAHP reports annually to the State on their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(3)) 3.10.7 X The State assures that it screens and enrolls, and periodically revalidates, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the requirements of part 455, subparts B and E. This requirement also extends to PCCMs and PCCM entities to the extent that the primary care case manager is not otherwise enrolled with the State to provide services to fee-for-service beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and

38 438.608(b)) This provision was added to the MCO contracts with amendments of 10/1/2018, effective retroactively to 1/1/2018. 3.10.8 X The State assures that it reviews the ownership and control disclosures submitted by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42 CFR 457.1285, cross referencing 42 CFR 438.602(c)) 3.10.9 X The State assures that it confirms the identity and determines the exclusion status of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine checks of Federal databases. If the State finds a party that is excluded, the State promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes action consistent with 42 CFR 438.610(c). (42 CFR 457.1285, cross referencing 42 CFR 438.602(d)) 3.10.10 X The State assures that it receives and investigates information from whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or PCCM entity, subcontractors, or network providers receiving Federal funds under this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f)) 3.10.11 X The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with which the State contracts are not located outside of the United States and that no claims paid by an MCO, PIHP, or PAHP to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (42 CFR 457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the Social Security Act) 3.10.12 The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit to the State the following data, documentation, and information: X Encounter data in the form and manner described in 42 CFR 438.818. X Data on the basis of which the State determines the compliance of the MCO, PIHP, or PAHP with the medical loss ratio requirement described in 42 CFR 438.8. X Data on the basis of which the State determines that the MCO, PIHP or PAHP has made adequate provision against the risk of insolvency as required under 42 CFR 438.116. X Documentation described in 42 CFR 438.207(b) on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR 438.206.

39 X Information on ownership and control described in 42 CFR 455.104 of this chapter from MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors as governed by 42 CFR 438.230. X The annual report of overpayment recoveries as required in 42 CFR 438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a))

3.10.13 The State assures that: X It requires that the data, documentation, or information submitted in accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a), is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification. (42 CFR 457.1285, cross referencing 42 CFR 438.606(a)) X It requires that the certification includes an attestation that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR 438.604 are accurate, complete, and truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and X It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285, cross referencing 42 CFR 438.604(c))

3.10.14 X The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors provides: written disclosure of any prohibited affiliation under 42 CFR 438.610, written disclosure of and information on ownership and control required under 42 CFR 455.104, and reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR 438.608(c)) 3.10.15 X The State assures that services are provided in an effective and efficient manner. (Section 2101(a)) 3.10.16 X The State assures that it operates a Web site that provides: • The documentation on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services; • Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors; and • The results of any audits conducted under 42 CFR 438.602(e). (42 CFR 457.1285, cross-referencing to 42 CFR 438.602(g)).

40 DHS contracts with MDH to review the MCOs’ network adequacy as part of the HMO licensing process. The reports are posted at http://www.health.state.mn.us/divs/hpsc/mcs/financial.htm (select an MCO, scroll down to “Quality Assurance Examinations” and the section of the report is “IV. Access and Availability.”)

DHS reviews all encounter data as it arrives and rejects each line of data that is non-compliant; in the 2019 contract, DHS is introducing a reconciliation of financial vs encounter data. In addition, the OLA is in the process of auditing encounter data (see https://www.auditor.leg.state.mn.us/fad/2018/fad18-10.htm)

MDH, as part of HMO licensing, reviews all financial reporting from HMOs. Reports are posted at http://www.health.state.mn.us/divs/hpsc/mcs/financial.htm.

The information on MCO ownership and control, as well as audit results are or will be posted to this website by the end of the year: https://mn.gov/dhs/partners-and-providers/news-initiatives-reports- workgroups/minnesota-health-care-programs/managed-care-reporting/reports- audits.jsp

3.11 Sanctions Guidance: Only States with MCOs need to answer the next three assurances (3.11.1 through 3.11.3).

Intermediate sanctions are defined at 42 CFR 438.702(a)(4) as: (1) Civil money penalties; (2) Appointment of temporary management (for an MCO); (3) Granting enrollees the right to terminate enrollment without cause; (4) Suspension of all new enrollment; and (5) Suspension of payment for beneficiaries.

3.11.1 X The State assures that it has established intermediate sanctions that it may impose if it makes the determination that an MCO has acted or failed to act in a manner specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR 438.700) 3.11.2 X The State assures that it will impose temporary management if it finds that an MCO has repeatedly failed to meet substantive requirements of part 457 subpart L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b))

41 3.11.3 X The State assures that if it imposes temporary management on an MCO, the State allows enrollees the right to terminate enrollment without cause and notifies the affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) Guidance: Only states with PCCMs, or PCCM entities need to answer the next assurance (3.11.4). 3.11.4 Does the State establish intermediate sanctions for PCCMs or PCCM entities? Yes No

Guidance: Only states with MCOs and states that answered yes to assurance 3.11.4 need to complete the next three assurances (3.11.5 through 3.11.7). 3.11.5 X The State assures that before it imposes intermediate sanctions, it gives the affected entity timely written notice. (42 CFR 457.1270, cross referencing 42 CFR 438.710(a)) 3.11.6 X The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity, it provides a pre-termination hearing and written notice of the decision as specified in 42 CFR 438.710(b). If the decision to terminate is affirmed, the State assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving CHIP services following the effective date of termination. (42 CFR 457.1270, cross referencing 42 CFR 438.710(b)) 3.11.7 X The State assures that it will give CMS written notice that complies with 42 CFR 438.724 whenever it imposes or lifts a sanction for one of the violations listed in 42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724) 3.12 Quality Measurement and Improvement; External Quality Review Guidance: The State should complete Sections 7 (Quality and Appropriateness of Care) and 9 (Strategic Objectives and Performance Goals and Plan Administration) in addition to Section 3.12. Guidance: States with MCO(s), PIHP(s), PAHP(s), or certain PCCM entity/ies (PCCM entities whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes - see 42 CFR 457.1240(f)) - should complete the applicable sub-sections for each entity type in this section, regarding 42 CFR 457.1240 and 1250.

42 3.12.1 Quality Strategy Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities need to complete section 3.12.1. 3.12.1.1 X The State assures that it will draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality strategy must include the following items: • The State-defined network adequacy and availability of services standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68 and 438.206 and examples of evidence-based clinical practice guidelines the State requires in accordance with 42 CFR 438.236; • A description of: o The quality metrics and performance targets to be used in measuring the performance and improvement of each MCO, PIHP, and PAHP with which the State contracts, including but not limited to, the performance measures reported in accordance with 42 CFR 438.330(c); and o The performance improvement projects to be implemented in accordance with 42 CFR 438.330(d), including a description of any interventions the State proposes to improve access, quality, or timeliness of care for beneficiaries enrolled in an MCO, PIHP, or PAHP; • Arrangements for annual, external independent reviews, in accordance with 42 CFR 438.350, of the quality outcomes and timeliness of, and access to, the services covered under each contract; • A description of the State's transition of care policy required under 42 CFR 438.62(b)(3); • The State's plan to identify, evaluate, and reduce, to the extent practicable, health disparities based on age, race, ethnicity, sex, and primary language; • For MCOs, appropriate use of intermediate sanctions that, at a minimum, meet the requirements of subpart I of 42 CFR Part 438; • A description of how the State will assess the performance and quality outcomes achieved by each PCCM entity; • The mechanisms implemented by the State to comply with 42 CFR 438.208(c)(1) (relating to the identification of persons with special health care needs); • Identification of the external quality review (EQR)-related activities for which the State has exercised the option under 42 CFR 438.360 (relating to nonduplication of EQR-related activities), and explain the

43 rationale for the State's determination that the private accreditation activity is comparable to such EQR-related activities; • Identification of which quality measures and performance outcomes the State will publish at least annually on the Web site required under 42 CFR 438.10(c)(3); and • The State's definition of a “significant change” for the purposes of updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b))

3.12.1.2 X The State assures that the goals and objectives for continuous quality improvement in the quality strategy are measurable and take into consideration the health status of all populations in the State served by the MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(2)) 3.12.1.3 X The State assures that for purposes of the quality strategy, the State provides the demographic information for each CHIP enrollee to the MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(6)) 3.12.1.4 X The State assures that it will review and update the quality strategy as needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)) 3.12.1.5 X The State assures that its review and updates to the quality strategy will include an evaluation of the effectiveness of the quality strategy conducted within the previous 3 years and the recommendations provided pursuant to 42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(i) and (iii). 3.12.1.6 X The State assures that it will submit to CMS: • A copy of the initial quality strategy for CMS comment and feedback prior to adopting it in final; and • A copy of the revised strategy whenever significant changes are made to the document, or whenever significant changes occur within the State's CHIP program, including after the review and update required every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(3)) 3.12.1.7 X Before submitting the strategy to CMS for review, the State assures that when it drafts or revises the State’s quality strategy it will:

44 • Make the strategy available for public comment; and • If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with Tribes in accordance with the State's Tribal consultation policy. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1)) 3.12.1.8 X The State assures that it makes the results of the review of the quality strategy (including the effectiveness evaluation) and the final quality strategy available on the Web site required under 42 CFR 438.10(c)(3). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and (d)) 3.12.2 Quality Assessment and Performance Improvement Program 3.12.2.1 Quality Assessment and Performance Improvement Program: Measures and Projects Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next two assurances (3.12.2.1.1 and 3.12.2.1.2). 3.12.2.1.1 X The State assures that it requires that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The elements of the assessment and program include at least: • Standard performance measures specified by the State; • Any measures and programs required by CMS (42 CFR 438.330(a)(2); • Performance improvement projects that focus on clinical and non-clinical areas, as specified in 42 CFR 438.330(d); • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c); • Mechanisms to detect both underutilization and overutilization of services; and • Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under 42 CFR 457.1240(e) and Section 3.12.1 of this template). (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(b) and (c)(1))

Guidance: A State may request an exemption from including the

45 performance measures or performance improvement programs established by CMS under 42 CFR 438.330(a)(2), by submitting a written request to CMS explaining the basis for such request. 3.12.2.1.2 X The State assures that each MCO, PIHP, and PAHP’s performance improvement projects are designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction. The performance improvement projects include at least the following elements: • Measurement of performance using objective quality indicators; • Implementation of interventions to achieve improvement in the access to and quality of care; • Evaluation of the effectiveness of the interventions based on the performance measures specified in 42 CFR 438.330(d)(2)(i); and • Planning and initiation of activities for increasing or sustaining improvement. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(2)) Guidance: Only states with a PCCM entity whose contract with the State provides for shared savings, incentive payments or other financial reward for improved quality outcomes need to, complete the next assurance (3.12.2.1.3).

3.12.2.1.3 The State assures that it requires that each PCCM entity establishes and implements an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The assessment and program must include: • Standard performance measures specified by the State; • Mechanisms to detect both underutilization and overutilization of services; and • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c). (42 CFR 457.1240(a) and (b), cross referencing to 42 CFR 438.330(b)(3) and (c)) 3.12.2.2 Quality Assessment and Performance Improvement Program: Reporting and Effectiveness Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.2.2.

46 3.12.2.2.1 X The State assures that each MCO, PIHP, and PAHP reports on the status and results of each performance improvement project conducted by the MCO, PIHP, and PAHP to the State as required by the State, but not less than once per year. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(3)) 3.12.2.2.2 X The State assures that it annually requires each MCO, PIHP, and PAHP to:

1) Measure and report to the State on its performance using the standard measures required by the State;

2) Submit to the State data specified by the State to calculate the MCO's, PIHP's, or PAHP's performance using the standard measures identified by the State; or

3) Perform a combination of options (1) and (2) of this assurance. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2))

3.12.2.2.3 X The State assures that the State reviews, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP and PCCM entity. The State’s review must include: • The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report; and • The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(e)(1)) 3.12.3 Accreditation Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.3. 3.12.3.1 X The State assures that it requires each MCO, PIHP, and PAHP to inform the state whether it has been accredited by a private independent accrediting entity, and, if the MCO, PIHP, or PAHP has received accreditation by a private independent accrediting agency, that the MCO, PIHP, and PAHP authorizes the private independent accrediting entity to provide the State a copy of its recent accreditation review that includes the MCO, PIHP, and PAHP’s accreditation status, survey type, and level (as applicable); accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings; and expiration date of the accreditation. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(a) and (b)).

47 3.12.3.2 X The State assures that it will make the accreditation status for each contracted MCO, PIHP, and PAHP available on the Web site required under 42 CFR 438.10(c)(3), including whether each MCO, PIHP, and PAHP has been accredited and, if applicable, the name of the accrediting entity, accreditation program, and accreditation level; and update this information at least annually. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(c)) This information is currently available on the website of the Minnesota Department of Health. Information will be posted to the DHS website by the end of this year.

https://mn.gov/dhs/partners-and-providers/news-initiatives-reports- workgroups/minnesota-health-care-programs/managed-care- reporting/reports-audits.jsp 3.12.4 Quality Rating Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete Section 3.12.4. X The State assures that it will implement and operate a quality rating system that issues an annual quality rating for each MCO, PIHP, and PAHP, which the State will prominently display on the Web site required under 42 CFR 438.10(c)(3), in accordance with the requirements set forth in 42 CFR 438.334. (42 CFR 457.1240(d)) Guidance: States will be required to comply with this assurance within 3 years after CMS, in consultation with States and other Stakeholders and after providing public notice and opportunity for comment, has identified performance measures and a methodology for a Medicaid and CHIP managed care quality rating system in the Federal Register. 3.12.5 Quality Review Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5 and 3.12.5.1. X The State assures that each contract with a MCO, PIHP, PAHP, or PCCM entity requires that a qualified EQRO performs an annual external quality review (EQR) for each contracting MCO, PIHP, PAHP or PCCM entity, except as provided in 42 CFR 438.362. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(a)) 3.12.5.1 External Quality Review Organization 3.12.5.1.1 X The State assures that it contracts with at least one external quality review organization (EQRO) to conduct either EQR alone or EQR

48 and other EQR-related activities. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(a)) 3.12.5.1.2 X The State assures that any EQRO used by the State to comply with 42 CFR 457.1250 must meet the competence and independence requirements of 42 CFR 438.354 and, if the EQRO uses subcontractors, that the EQRO is accountable for and oversees all subcontractor functions. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.354 and 42 CFR 438.356(b) through (d)) 3.12.5.2 External Quality Review-Related Activities Guidance: Only states with MCOs, PIHPs, or PAHPs need to complete the next three assurances (3.12.5.2.1 through 3.12.5.2.3). Under 42 CFR 457.1250(a), the State, or its agent or EQRO, must conduct the EQR-related activity under 42 CFR 438.358(b)(1)(iv) regarding validation of the MCO, PIHP, or PAHP’s network adequacy during the preceding 12 months; however, the State may permit its contracted MCO, PIHP, and PAHPs to use information from a private accreditation review in lieu of any or all the EQR-related activities under 42 CFR 438.358(b)(1)(i) through (iii) (relating to the validation of performance improvement projects, validation of performance measures, and compliance review). 3.12.5.2.1 X The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(1)(i) through (iv) (relating to the validation of performance improvement projects, validation of performance measures, compliance review, and validation of network adequacy) will be conducted on all MCOs, PIHPs, or PAHPs. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(b)(1))

3.12.5.2.2 X The State assures that if it elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will document the use of nonduplication in the State’s quality strategy. (42 CFR 457.1250(a), cross referencing 438.360, 438.358(b)(1)(i) through (b)(1)(iii), and 438.340) 3.12.5.2.3 X The State assures that if the State elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will ensure that all information from a Medicare or private accreditation review for an MCO, PIHP, or PAHP will be furnished to the EQRO for analysis

49 and inclusion in the EQR technical report described in 42 CFR 438.364. ((42 CFR 457.1250(a), cross referencing to 42 CFR 438.360(b)) Guidance: Only states with PCCM entities need to complete the next assurance (3.12.5.2.4). 3.12.5.2.4 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(2) (cross-referencing 42 CFR 438.358(b)(1)(ii) and (b)(1)(iii)) will be conducted on all PCCM entities, which include: • Validation of PCCM entity performance measures required in accordance with 42 CFR 438.330(b)(2) or PCCM entity performance measures calculated by the State during the preceding 12 months; and • A review, conducted within the previous 3-year period, to determine the PCCM entity’s compliance with the standards set forth in subpart D of 42 CFR part 438 and the quality assessment and performance improvement requirements described in 42 CFR 438.330. (42 CFR 457.1250(a), cross referencing to 438.358(b)(2))

3.12.5.3 External Quality Review Report Guidance: All states with MCOs, PIHPs, PAHPs, PCCMs or PCCM entities need to complete Sections 3.12.5.3. 3.12.5.3.1 X The State assures that data obtained from the mandatory and optional, if applicable, EQR-related activities in 42 CFR 438.358 is used for the annual EQR to comply with 42 CFR 438.350 and must include, at a minimum, the elements in §438.364(a)(2)(i) through (iv). (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(a)(2))

3.12.5.3.2 X The State assures that only a qualified EQRO will produce the EQR technical report (42 CFR 438.364(c)(1)).

3.12.5.3.3 X The State assures that in order for the qualified EQRO to perform an annual EQR for each contracting MCO, PIHP, PAHP or PCCM entity under 42 CFR 438.350(a) that the following conditions are met: • The EQRO has sufficient information to use in performing the review;

50 • The information used to carry out the review must be obtained from the EQR-related activities described in 42 CFR 438.358 and, if applicable, from a private accreditation review as described in 42 CFR 438.360; • For each EQR-related activity (mandatory or optional), the information gathered for use in the EQR must include the elements described in 42 CFR 438.364(a)(2)(i) through (iv); and • The information provided to the EQRO in accordance with 42 CFR 438.350(b) is obtained through methods consistent with the protocols established by the Secretary in accordance with 42 CFR 438.352. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(b) through (e)) 3.12.5.3.4 X The State assures that the results of the reviews performed by a qualified EQRO of each contracting MCO, PIHP, PAHP, and PCCM entity are made available as specified in 42 CFR 438.364 in an annual detailed technical report that summarizes findings on access and quality of care. The report includes at least the following items: • A description of the manner in which the data from all activities conducted in accordance with 42 CFR 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR 438.310(c)(2)); • For each EQR-related activity (mandatory or optional) conducted in accordance with 42 CFR 438.358: o Objectives; o Technical methods of data collection and analysis; o Description of data obtained, including validated performance measurement data for each activity conducted in accordance with 42 CFR 438.358(b)(1)(i) and (ii); and o Conclusions drawn from the data; • An assessment of each MCO's, PIHP's, PAHP's, or PCCM entity's strengths and weaknesses for the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Recommendations for improving the quality of health care services furnished by each MCO, PIHP, PAHP, or PCCM entity, including how the State can target goals and objectives in the quality strategy, under 42 CFR 438.340, to better support

51 improvement in the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Methodologically appropriate, comparative information about all MCOs, PIHPs, PAHPs, and PCCM entities, consistent with guidance included in the EQR protocols issued in accordance with 42 CFR 438.352(e); and • An assessment of the degree to which each MCO, PIHP, PAHP, or PCCM entity has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(f) and 438.364(a)) 3.12.5.3.5 X The State assures that it does not substantively revise the content of the final EQR technical report without evidence of error or omission. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(b)) 3.12.5.3.6 X The State assures that it finalizes the annual EQR technical report by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(1)) 3.12.5.3.7 X The State assures that it posts the most recent copy of the annual EQR technical report on the Web site required under 42 CFR 438.10(c)(3) by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(i)) 3.12.5.3.8 X The State assures that it provides printed or electronic copies of the information specified in 42 CFR 438.364(a) for the annual EQR technical report, upon request, to interested parties such as participating health care providers, enrollees and potential enrollees of the MCO, PIHP, PAHP, or PCCM, beneficiary advocacy groups, and members of the general public. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(ii)) 3.12.5.3.9 X The State assures that it makes the information specified in 42 CFR 438.364(a) for the annual EQR technical report available in alternative formats for persons with disabilities, when requested. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(3)) 3.12.5.3.10 X The State assures that information released under 42 CFR 438.364 for the annual EQR technical report does not disclose the identity or other protected health information of any patient. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(d))

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Minnesota MN-20-0015

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

December 18, 2023

Julie Marquardt Acting Medicaid Director State of Minnesota, Department of Human Services 540 Cedar Street St. Paul, MN 55167‐0983

Dear Director Marquardt,

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) MN- 20-0015, received on June 23, 2020, with additional information received on November 15, 2023, has been approved. This SPA has an effective date of October 24, 2019, except as otherwise noted below.

Through this SPA, Minnesota has demonstrated compliance with the SUPPORT Act at section 2103(c)(5) of the Social Security Act (SSA), which requires child health and pregnancy related assistance to include coverage of services necessary to prevent, diagnose, and treat a broad range of behavioral health symptoms and disorders. Minnesota currently provides partial hospitalization only to individuals with a mental health diagnosis or with a co-occurring mental health and substance use disorder (SUD) diagnosis. Currently, individuals with a SUD diagnosis can access levels of care similar to a partial hospitalization benefit, but it is not a state plan benefit.

As part of this SPA, effective January 1, 2025, Minnesota will provide increased access to partial hospitalization by making this service available to individuals diagnosed with only a SUD diagnosis. This modification is part of legislation passed in Minnesota to adopt provisions to comply with the American Society of Addiction Medicine (ASAM) criteria in SUD treatment services and programs. Minnesota will notify CMS if there are any changes to this effective date.

Additionally, Section 2103(c)(5)(B) of the Act requires that these behavioral health services be delivered in a culturally and linguistically appropriate manner. Minnesota demonstrated compliance by providing the necessary assurances and benefit descriptions that the state covers a range of behavioral health services in a culturally and linguistically appropriate manner.

Your Project Officer is Chanelle Parkar. She is available to answer your questions concerning this amendment and other CHIP-related matters. Her contact information is as follows:

Page 2 – Director Marquardt

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850 Telephone: (667) 290-8798 E-mail: chanelle.parkar@cms.hhs.gov

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

Sincerely,

Sarah deLone Director /Signed by Sarah deLone/

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

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

State/Territory:_____MINNESOTA_________________________________________________

(Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))_______________________________________________________ (Signature of Deputy Medicaid Director, Date Signed)

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

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

Name: _Matt Anderson___ Position/Title: Assistant Commissioner, Health Care Administration, &Medicaid Director Name: _Julie Marquardt_

Position/Title: Director, Purchasing & Service Delivery

Name: _Sarah Orange

Position/Title: Health Care Budget & Finance Director

Disclosure Statement This information is being collected to pursuant to 42 U.S.C. 1397aa, which requires states to submit a State Child Health Plan in order to receive federal funding. This mandatory information collection will be used to demonstrate compliance with all requirements of title XXI of the Act and implementing regulations at 42 CFR part 457. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). Public burden for all of the collection of information requirements under this control number is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-2605, Baltimore, Maryland 21244-1850.

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

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

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

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SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

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

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

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6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretaryapproved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of preexisting medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health

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benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

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

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

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

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes

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of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

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

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

Mail Stop - S2-01-16

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Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

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

Original Plan Effective Date: 9/30/1998

Implementation Date: 9/30/1998

SPA 20-0015 Purpose of SPA: Comply with requirements in the Support Act Proposed effective date: 10/24/2019

Effective January 1, 2025, all individuals with only a substance use disorder diagnosis will also be eligible to receive partial hospitalization services, as modified by the fourth edition of the ASAM standards..

Proposed implementation date: 10/24/2019

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. On 5/12/2020, tribal chairs, tribal health directors, Urban Indian Health Centers, and Indian Health Service directors were given notice and 30-day comment period for this CHIP state plan amendment.

TN No: Approval Date: ___________

Effective Date: 10/24/2019

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

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

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

Special Health Initiative:

Minnesota will use additional CHIP funds, up to 10 percent of federal CHIP expenditures (after administrative costs for the CHIP populations), for other child health assistance as authorized under §2105(a)(2) of the Act. Such assistance will be costs for postpartum months of undocumented noncitizen mothers of unborn children that are paid on a fee-for-service basis. [Approved under SPA number 090004)

2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)); (ARRA #2, CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice.

This process is the same as described in the Medicaid State Plan.

Tribal Consultation Requirements [as described in the Medicaid State Plan, section 1.4 of the preprint]

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In compliance with §1902(a)(73) and 2107(e)(1)(C) of the Social Security Act, the state agency meets on a quarterly basis with tribal health directors of federally recognized tribes, Indian Health Service (IHS)representatives, and urban Indian healthcare providers to seek advice on matters related to Medicaid and CHIP programs, including consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prepared for submission to CMS.

Ongoing consultation: Since 1999, the state has met on a quarterly basis with tribal health directors, Indian Health Service representatives, and urban Indian healthcare providers. The quarterly meetings provide a forum for the state to solicit input from the providers on any issues of interest to them, including proposed changes to state health care programs, updates on state and federal law and regulation changes and funding opportunities. State agency policy staff attend the meetings to provide information, respond to questions, and accept comments from the providers.

Consultation regarding state plan amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects: The state agency has designated a staff person in the Medicaid Director's office to act as a liaison to the Indian health care providers regarding consultation. The liaison sends written notification to Tribal Chairs, Tribal Health Directors, and Tribal Social Services Directors, the Indian Health Service Area Office Director, and the Director of the Minneapolis Indian Health Board clinic at least 30 days prior to the anticipated submission of all waiver requests, waiver renewals, or waiver amendments. When a 3O day notice is not possible, the longest practicable notice timeframe will be utilized. The liaison provides written notice to Indian health care programs 30 days in advance of the anticipated submission of all proposed state plan amendments likely to have a direct effect on Indians, Indian health programs, or urban Indian organizations. Changes that are likely to have a direct effect on Indians, Indian health programs, or urban Indian organizations are those that would impact eligibility determinations, reduce payment rates, change payment methodologies, reduce covered services, or change provider qualification requirements.

When a deadline for submission of a state plan amendment is outside the control of the agency, or in severely time-limited situations, the agency expedites the process and may provide, at a minimum, 10 days advance written notice of the change. Notices include a brief description of the proposal, its likely impact on Indian people or Indian health care providers, and a process and timeline for comment. At the request of an Indian health care provider, the liaison will send more information about any proposal. The liaison arranges for appropriate state agency policy staff to meet with Indian health care providers to receive their input and to answer questions. This consultation may take place as pan of a Quarterly Tribal Health Directors meeting or via a separate meeting, conference call, or other mechanism, as appropriate. The liaison forwards all comments

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received from Indian health care providers to appropriate state policy staff for their response.

When an Indian health care provider has requested changes to a proposed state plan amendment or waiver request, renewal, or amendment, the state agency liaison reports back on whether the change is included in the submission, or why it is not included. The state agency liaison informs the Indian health care providers when the State's waiver or state plan changes are approved or disapproved by CMS, and would include CMS' rational for disapproval.

For each state plan or waiver change, the state agency liaison maintains a record of the notification process; the consultation process, including written correspondence from Indian health care providers and notes of meetings or other discussions with them, and the outcome of the process. Section 6. Coverage Requirements for Children’s Health Insurance

6.2-BH Behavioral Health Coverage Section 2103(c)(5) requires that states provide coverage to prevent, diagnose, and treat a broad range of mental health and substance use disorders in a culturally and linguistically appropriate manner for all CHIP enrollees, including pregnant women and unborn children.

Guidance: Please attach a copy of the state’s periodicity schedule. For pregnancy-related coverage, please describe the recommendations being followed for those services.

6.2.1- BH Periodicity Schedule The state has adopted the following periodicity schedule for behavioral health screenings and assessments. Please specify any differences between any covered CHIP populations:

State- developed schedule - DHS C & TC Schedule of Age-Related Screenings The schedule mirrors that of the AAP Bright Futures. There is no periodicity schedule for 21 and older. American Academy of Pediatrics/ Bright Futures Other Nationally recognized periodicity schedule (please specify: ) Other (please describe: )

For mothers of unborn children, the schedule applies to individuals under age 21. [CHIP expansion infants are covered by Medicaid State Plan benefits]

6.2.22.

EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act

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6.2.22.1 The state assures that any limitations applied to the amount, duration, and scope of benefits described in Sections 6.2 and 6.3- BH of the CHIP state plan can be exceeded as medically necessary.

6.3- BH Covered Benefits. Please check off the behavioral health services that are provided to the state’s CHIP populations, and provide a description of the amount, duration, and scope of each benefit. For each benefit, please also indicate whether the benefit is available for mental health and/or substance use disorders. If there are differences in benefits based on the population or type of condition being treated, please specify those differences.

If EPSDT is provided, as described at Section 6.2.22 and 6.2.22.1, the state should only check off the applicable benefits. It does not have to provide additional information regarding the amount, duration, and scope of each covered behavioral health benefit. MN provides EPSDT at 6.2.22 and 6.2.22.1, in accordance with the benefits in its Medicaid State Plan, Attachment 3.1-A (attached). The benefits checked below apply to the mothers of unborn children who are either under age 21 or age 21 and older. Descriptions of services apply to enrollees age 21 and older under the Medicaid benefit set.

Unless otherwise stated, services are provided as medically necessary services and as approved in a treatment service plan for either mental health or substance use disorders.

Guidance: Please include a description of the services provided in addition to the behavioral health screenings and assessments described in the assurance below at 6.3.1.1-BH.

6.3.1- BH Behavioral health screenings and assessments. (Section 2103(c)(6)(A)) Applicable to enrollees under age 21 under EPSDT, and age 21 and older. See Minnesota Chapter 245I.10; and for SUD, see Minnesota Chapter 245G.05.

6.3.1.1- BH The state assures that all developmental and behavioral health recommendations outlined in the AAP Bright Futures periodicity schedule and United States Public Preventive Services Task Force (USPSTF) recommendations graded as A and B are covered as a part of the CHIP benefit package, as appropriate for the covered populations.

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools in primary care practice, providing education, training, and technical resources, and covering the costs of administering or purchasing the tools.

6.3.1.2- BH The state assures that it will implement a strategy to facilitate the use of age-appropriate validated behavioral health screening tools in primary care settings. Please describe how the state will facilitate the use of validated screening tools.

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Managed Care Organization (MCO) contracts requires the use of age-appropriate child screenings for behavioral health in primary care clinics. See the attached model contract sections for descriptions of adult and child mental health assessments. Age-related requirements for adults and children are found in state law, as noted above.

6.1.30 (1) The MCO will require behavioral health Providers performing diagnostic assessments to screen all adolescent Enrollees upon initial access of behavioral health services for the presence of co-occurring mental illness and substance use disorder using screening tools on the IDDT web page: https://mn.gov/dhs/partners-and-providers/policies-procedures/childrens- mentalhealth/

6.3.2- BH Outpatient services (Sections 2110(a)(11) and 2110(a)(19))

Applicable to enrollees under age 21 with EPSDT, and age 21 and older

Guidance: Psychosocial treatment includes services such as psychotherapy, group therapy, family therapy and other types of counseling services.

6.3.2.1- BH Psychosocial treatment; applicable to enrollees under age 21 with EPSDT, and age 21 and older

Provided for: Mental Health Substance Use Disorder

Treatment methods include individual therapy, family or group therapy, and other types of specialized treatment services, and including counseling related to adjustment to physical disabilities or chronic illness.

6.3.2.2- BH Tobacco cessation; applicable to enrollees under age 21 with EPSDT, and age 21 and older

Provided for: Substance Use Disorder

Includes education and assistance for smoking cessation as part of prenatal education. In addition to counseling, services include medications like, the patch, gum, lozenges, nicotine inhaler or nasal spray, Bupropion, or Chantix. The state covers all FDA- approved medications.

Guidance: In order to provide a benefit package consistent with section 2103(c)(5) of the Act, MAT benefits are required for the treatment of opioid use disorders. However, if the state provides MAT for other SUD conditions, please include a description of those benefits below at section 6.3.2.3- BH.

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6.3.2.3- BH Medication Assisted Treatment; applicable to enrollees under age 21 with EPSDT, and age 21 and older

Provided for: Substance Use Disorder

6.3.2.3.1- BH Opioid Use Disorder

This service uses medication as a therapeutic support in conjunction with individual and group therapy. This includes but is not limited to methadone, naltrexone, and buprenorphine. The state covers all FDA-approved medications.

6.3.2.3.2- BH Alcohol Use Disorder

See 6.3.2.3.1

6.3.2.3.3- BH Other

6.3.2.4- BH Peer Support; applicable to enrollees under age 21 with EPSDT, and age 21 and older

Provided for: Mental Health Substance Use Disorder

Recovery peers provide mentoring, education, advocacy and nonclinical recovery support to the recipient.

6.3.2.5- BH Caregiver Support; applicable to enrollees under age 21 with EPSDT

Provided for: Mental Health Substance Use Disorder

See attachment on EPSDT for full description of Children’s Therapeutic Services and Supports

6.3.2.6- BH Respite Care

Provided for: Mental Health Substance Use Disorder

6.3.2.7- BH Intensive in-home services; applicable to enrollees under age 21 with EPSDT, and age 21 and older

Provided for: Mental Health Substance Use Disorder

See 6.3.9 for description.

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6.3.2.8- BH Intensive outpatient; applicable to enrollees under age 21 with EPSDT, and age 21 and older; those with dual diagnoses may have access to such services. Provided for: Mental Health Substance Use Disorder

See 6.3.9 for description for age 21 and older Mental Health intensive services.

See p. 17rr of EPSDT attachment for intensive outpatient services for under 21.

SUD providers are allowed to bill up to 30 hours per week of individual and group therapy which meets the ASAM definition for both intensive outpatient (requiring between 9 to 19 hours/week).

6.3.2.9- BH Psychosocial rehabilitation; applicable to enrollees under age 21 with EPSDT

Provided for: Mental Health X Substance Use Disorder

See pp. 17d – 17f of EPSDT attachment for full description.

Components of children’s Therapeutic Services and Supports A. Psychotherapy: patient and/or family; family, and group B. Individual family or groups skills training designed to facilitate the acquisition of psychosocial skills medically necessary to rehabilitate the child C. Crisis assistance D. Mental health behavioral aide

A & B may be combined in a day treatment program provided by multidisciplinary staff under the supervision of a mental health professional, at an outpatient hospital, community mental health center, or county contracted day treatment provider.

Guidance: If the state considers day treatment and partial hospitalization to be the same benefit, please indicate that in the benefit description. If there are differences between these benefits, such as the staffing or intensity of the setting, please specify those in the description of the benefit’s amount, duration, and scope.

6.3.3- BH Day Treatment; applicable to enrollees under age 21 with EPSDT, and age 21 and older Provided for: Mental Health Substance Use Disorder

The state does not consider day treatment and partial hospitalization services to be the same benefit. Day treatment for mental health is authorized for 3 hours/day, up to 15 hours/week. Prior authorization is required. Adult day treatment includes at least one

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hour of group psychotherapy and must include group time focused on rehabilitative interventions or other therapeutic services that are provided by a multidisciplinary staff.

Day treatment is not offered for SUD, although a person with a dual diagnosis may be admitted to a mental health day treatment program.

6.3.3.1- BH Partial Hospitalization

Provided for: Mental Health X Substance Use Disorder effective January 1, 2025

Partial hospitalization (as authorized under title XVIII/Medicare) for mental health covers up to 30 hours/week. The first 21 days are covered without prior authorization, and additional days following that require prior authorization. Prior authorization is needed for any days if fewer than 5 hours/day are provided for a person 18 and older; or fewer than 4 hours/day for a person under age 19. A person with a dual diagnosis may be admitted to a partial hospitalization program.

Under the existing Minnesota Model of Care, the state provides outpatient behavioral health services in a manner that allows individuals with a substance use disorder to access levels of care similar to a partial hospitalization benefit. Individuals may receive up to 30 hours per week of intensive outpatient care, which exceeds the ASAM criteria for partial hospitalization of 20 hours/week. If an individual exceeds 30 hours of care, a prior authorization would be required. The state does not impose a cap on the number of treatments provided and individuals may receive referrals through treatment coordination if additional services are necessary.

Effective January 1, 2025, all individuals with only a substance use disorder diagnosis will be eligible to receive partial hospitalization services, as modified by the ASAM standards fourth edition.

6.3.4- BH

Inpatient services, including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Sections 2110(a)(10) and 2110(a)(18)); Applicable to enrollees under age 21 with EPSDT, and age 21 and older Provided for: Mental Health Substance Use Disorder

Inpatient hospital services include psychiatric care in an acute care hospital for individuals under age 21, or 21 and older, including extended stays. For individuals under age 21, inpatient services include care in a Medicare-certified psychiatric hospital.

Guidance: If applicable, please clarify any differences within the residential treatment benefit (e.g. intensity of services, provider types, or settings in which the residential treatment services are provided).

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6.3.4.1- BH Residential Treatment; applicable to enrollees under age 21 with EPSDT, and age 21 and older

Provided for: Mental Health Substance Use Disorder

Residential treatment limitations are established by the individual treatment plan. Residential treatment for children under age 21 includes psychiatric residential treatment programs (PRTF) as authorized in Medicaid. See 6.3.9 for description of residential treatment requirements for adults.

Residential SUD treatment offers 3 treatment levels: High intensity (30 hours /week); medium intensity (15 hours/week); low intensity (5 hours/week).

6.3.4.2- BH Detoxification. Covered as Withdrawal Management; applicable to enrollees under age 21 with EPSDT (age 18+ only), and age 21 and older

Provided for: Substance Use Disorder

Withdrawal management services on a 24-hour basis are covered, when meeting clinical monitoring requirements by medical professionals.

Clinically managed withdrawal management is an organized service that meets the ASAM level III.2.D level of care criteria by providing 24-hour structure, support, supervision, and observation for individuals who are intoxicated or experiencing withdrawal symptoms.

A medically monitored program meets the ASAM level III.7.D level of care criteria by providing 24-hour medically supervised evaluation and withdrawal management.

[Other detoxification services have separate licenses, and are county-funded.]

Guidance: Crisis intervention and stabilization could include services such as mobile crisis, or short term residential or other facility based services in order to avoid inpatient hospitalization.

6.3.5- BH Emergency services; applicable to enrollees under age 21 with EPSDT, and age 21 and older Provided for: Mental Health Substance Use Disorder

Also known as crisis intervention. See below.

6.3.5.1- BH Crisis Intervention and Stabilization; applicable to enrollees under age 21 with EPSDT, and age 21 and older

Provided for: Mental Health Substance Use Disorder

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For mental health, services include assessment, intervention and stabilization. For SUD, services include placement in detox or in a withdrawal management program.

6.3.6- BH Continuing care services Provided for: Mental Health Substance Use Disorder

6.3.7- BH Care Coordination; applicable to enrollees under age 21 with EPSDT, and age 21 and older

Provided for: Mental Health Substance Use Disorder

Minnesota currently covers the following care coordination services as defined in its Medicaid benefit set: Behavioral Health Home services; Health Homes (Minnesota’s patient centered medical home); SUD treatment coordination.

Treatment coordinators synchronize health services with identified patient needs, to facilitate the aims of the care plan. Activities include treatment follow-up, on-going needs assessments, life skills advocacy, education, service referral, and documentation.

If any recipient receiving a care coordination service has identified SUD as an area of concern, or has a SUD diagnosis, the care coordinator is expected to provide referral support to ensure that the person is connected with appropriate screening, diagnostic services, treatment services, and step-down services.

6.3.7.1- BH Intensive wraparound; applicable to enrollees under age 21 with EPSDT, and age 21 and older

Provided for: Mental Health Substance Use Disorder

See 6.3.9 for description of services applicable to adult-age individuals

6.3.7.2- BH Care transition services; applicable to enrollees under age 21 with EPSDT, and age 21 and older

Provided for: Mental Health Substance Use Disorder

Care coordination services include transition services, that is, changing or adding services providers or moving to a different level of care.

6.3.8- BH Case Management; applicable to enrollees under age 21 with EPSDT, and age 21 and older Provided for: Mental Health Substance Use Disorder

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Targeted case management, as defined in Medicaid, for children and adults with serious mental health needs.

Four types of targeted case management services are covered: child welfare; vulnerable adult/adult with developmental disability, adult and children’s mental health, and relocation coordination service. If any recipient receiving a targeted case management service has SUD identified as an area of concern, or has a SUD diagnosis, the case manager is expected to provide referral support to ensure that the person is connected with appropriate screening, diagnostic services, treatment services, and step-down services.

6.3.9- BH Other; applicable to enrollees age 21 and older Provided for: Mental Health Substance Use Disorder

Adult Rehabilitative Mental Health Services (ARMHS): The services are provided on a one-to-one basis or in a group in a recipient’s home, a relative’s home, school, place of employment, or other community setting, by a team of professionals. The services include a functional assessment, a treatment plan, assistance with basic living and social skills, community intervention to help retain stability and avoid decompensation, and certified peer specialist support.

Intensive Outpatient Dialectical Behavior Therapy Services: Must be approved by a mental health professional. A recipient appropriate for dialectical behavior therapy must have mental health needs that cannot be met with other available community-based services or that must be provided concurrently with other community based services and: 1. have a diagnosis of borderline personality disorder; or 2. have multiple mental health diagnoses and is exhibiting behaviors characterized by impulsivity, intentional self-harm behavior and is at significant risk of death, significant morbidity, disability and/or severe dysfunction across multiple domains.

Assertive Community Treatment Services (ACT): Services must be recommended by a mental health professional. Recipients must be over age 18. Individuals age 16 or 17 may receive ACT services upon approval by the Department.

Intensive Rehabilitation Treatment Services (IRTS): The services must be recommended by a mental health professional defined in item 6.d.A. after a diagnostic assessment and a functional assessment. They are provided pursuant to an individual treatment plan, and may include individualized or group services. These services are provided to a recipient age 18 and older meeting the same eligibility requirements for ACT services, but the recipient also requires the level of care and supervision provided in a residential setting. These services are designed to develop and enhance psychiatric

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System)

stability, personal and emotional adjustment, self-sufficiency, and skills to live in a more independent setting.

6.4- BH Assessment Tools

6.4.1- BH Please specify or describe all of the tool(s) required by the state and/or each managed care entity:

ASAM Criteria (American Society Addiction Medicine) Mental Health Substance Use Disorders InterQual Mental Health Substance Use Disorders MCG Care Guidelines Mental Health Substance Use Disorders CALOCUS/LOCUS (Adult) (Child and Adolescent Level of Care Utilization

Mental Health Substance Use Disorders

CASII (Child and Adolescent Service Intensity Instrument) Mental Health Substance Use Disorders CANS (Child and Adolescent Needs and Strengths) Mental Health Substance Use Disorders State-specific criteria (e.g. state law or policies) (please describe) Mental Health Substance Use Disorders

The managed care enrollee has a choice of using a Comprehensive Assessment or the state-based assessment tool established by state rule (known as a Rule 25 assessment). Mental health screenings, known as the GAIN SS, are included in each of these tools. The Rule 25 Assessment will be phased out by July of 2022.

When the Rule 25 assessment is used to determine appropriate treatment, an admitted client must still be given the comprehensive assessment to formulate a treatment plan.

State-specific criteria for adult and child mental health assessments are established in rule: Minn. Rule 9505.0372. Four types of diagnostic assessments are covered, when conducted in accordance with the requirements in the rule. Coverage of assessments

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includes neuropsychological testing, and psychological testing. The state relies on the professionals to select assessment tools that meet the standards in the rule.

As of 2/15/2022, diagnostic assessments for SUD service needs are governed by Minn. Stat 245G.05.

Plan-specific criteria (please describe) Mental Health Substance Use Disorders

Other WHO Disability Assessment Schedule Mental Health Substance Use Disorders

No specific criteria or tools are required Mental Health Substance Use Disorders

Guidance: Examples of facilitation efforts include requiring managed care organizations and their networks to use such tools to determine possible treatments or plans of care, providing education, training, and technical resources, and covering the costs of administering or purchasing the assessment tools.

6.4.2- BH Please describe the state’s strategy to facilitate the use of validated assessment tools for the treatment of behavioral health conditions.

In addition to diagnostic assessments for adults, a functional assessment using the WHO Disability Assessment Schedule 2.0, or the Level of Care Utilization System (LOCUS) assessment is required for treatment planning with regard to Intensive Rehabilitation Treatment Services (IRTS), and Adult Rehabilitative Mental Health Services (ARMHS).

Criteria that must be met in any diagnostic mental health assessment for adults or children are established by rule (see 6.4.1 and attached requirements in Minn. Rule 9505.0372). The state relies on the professionals to select assessment tools that meet the standards in the rule. In addition, the MN C & TC screening schedule provides a list of acceptable screening tools for providers, as well as recommending certain ones.

Effective 9/15/2022, diagnostic assessments for SUD service needs are governed by Minn. Stat. 245G.05, as provided by amendments to the Medicaid State Plan under MN-22-0024.

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6.2.5- BH Covered Benefits. The State assures the following related to the provision of behavioral health benefits in CHIP:

All behavioral health benefits are provided in a culturally and linguistically appropriate manner consistent with the requirements of section 2103(c)(6), regardless of delivery system.

The state will provide all behavioral health benefits consistent with 42 CFR 457.495 to ensure there are procedures in place to access covered services as well as appropriate and timely treatment and monitoring of children with chronic, complex or serious conditions.

Section 9. Strategic Objectives and Performance Goals and Plan Administration

Guidance: Section 9.9 can include discussion of community-based providers and consumer representatives in the design and implementation of the plan and the method for ensuring ongoing public involvement. Issues to address include a listing of public meetings or announcements made to the public concerning the development of the children's health insurance program or public forums used to discuss changes to the State plan.

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

Notice was given to the public on May 20, 2020 by e-mail to those requesting notification, with a 30-day comment period, and access to the proposed SPA on the DHS website.

9.9.2. For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), describe how and when prior public notice was provided as required in 42 CFR 457.65(b) through (d).

Notice was sent to tribal governments, health directors, Urban Indian Centers, and Indian Health Service facilities on May 20, 2020 with a 30-day comment period. No comments or questions were received.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Minnesota MN-21-0016

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

May 23, 2022

Cynthia MacDonald Assistant Commissioner and Minnesota Medicaid Director Health Care Administration Minnesota Department of Human Services 540 Cedar Street St. Paul, Minnesota 55164-0983

Dear Ms. MacDonald:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number MN-21-0016 submitted on June 30, 2021, has been approved. Through this SPA, Minnesota has demonstrated compliance with the American Rescue Plan Act of 2021 (ARP). This SPA has an effective date of March 11, 2021 and extends through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period, as described in section 1135(g)(1)(B) of the Social Security Act (the Act).

Section 9821 of the ARP amended sections 2103(c)(11)(B) and 2103(e)(2) of the Act to mandate coverage of COVID-19 testing, treatment, and vaccines and their administration without cost- sharing or amount, duration, or scope limitations. Sections 2103(c)(11)(B) and 2103(e)(2) of the Act also require states to cover, without cost sharing, the treatment of conditions that may seriously complicate COVID-19 treatment, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19. The state provided the necessary assurances to demonstrate compliance with the ARP in accordance with the requirements of sections 2103(c)(11)(B) and 2103(e)(2) of the Act.

Your Project Officer is Kathleen Connors de Laguna. She is available to answer your questions concerning this amendment and other CHIP-related matters. Her contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: 410 786-2256

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

Page 2 – Ms. MacDonald

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

Sincerely,

Amy Lutzky Deputy Director Children and Adult Health Programs Group Center for Medicaid and CHIP Services

/Signed by Amy Lutzky/

TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM (Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: ___MINNESOTA_______________________________________________

(Name of State/Territory) As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b)) ____________MINNESOTA___________________________________ (Signature of Deputy Medicaid Director, Date Signed) submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: _Julie Marquardt Position/Title: Acting Assistant Commissioner, Health Care Administration, &Medicaid Director Name: _Julie Marquardt_ Position/Title: Director, Purchasing & Service Delivery

Name: _Sarah Orange Position/Title: Health Care Budget & Finance Director

Disclosure Statement This information is being collected to pursuant to 42 U.S.C. 1397aa, which requires states to submit a State Child Health Plan in order to receive federal funding. This mandatory information collection will be used to demonstrate compliance with all requirements of title XXI of the Act and implementing regulations at 42 CFR part 457. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). Public burden for all of the collection of information requirements under this control number is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the

information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date. Original Plan Effective Date: 9/30/1998 Implementation Date: 9/30/1998

MN SPA 21-0016 SPA. Purpose of SPA: To implement the vaccine coverage provision of the American Rescue Plan Act, P.L. 117-2, section 9821 as of the effective date. Proposed Effective Date: March 11, 2021 Proposed Implementation Date: March 11, 2021 TN: Approval Date _________

Effective Date - March 11, 2021

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. On the same date as submission, June 30, 2021, tribal chairs, tribal health directors, Urban Indian Health Centers, and Indian Health Service directors were given notice of submission of this CHIP state plan amendment. No comments or questions have been submitted. This state plan amendment has no impact on tribes.

Section 6. Coverage Requirements for Children’s Health Insurance 6.2.27 Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28)) REQUIRED COVERAGE OF COVID–19 VACCINES AND TREATMENT Effective March 11, 2021, the state provides child health assistance without cost sharing, during the period beginning on the date of the enactment of this paragraph and ending on the last day of the first calendar quarter that begins one year after the last day of the emergency period described in section 1135(g)(1)(B) of the Act for all populations covered in the CHIP state child health plan: (A) Coverage of COVID–19 vaccines and the administration of the vaccine in accordance with the requirements of section 2103(c)(11)(A) of the Act; (B) Coverage of testing for COVID–19, in accordance with the requirements of section 2103(c)(11)(B) of the Act. • The state assures that coverage of COVID-19 testing is consistent with the Centers for Disease Control and Prevention (CDC) definitions of diagnostic and screening testing for COVID-19 and its recommendations for who should receive diagnostic and screening tests for COVID-19. • The state assures that coverage includes all types of FDA authorized COVID-19 tests. (C) The state assures that treatments for COVID-19 are provided without amount, duration, or scope limitations, in accordance with requirements of section 2103(c)(11)(B) of the Act, and that the state provides - Coverage of COVID-19 treatment coverage including specialized equipment and therapies (including preventive therapies). Coverage for treatment of an individual who is diagnosed with or presumed to have COVID–19, during the period during which such individual has (or is presumed to have) COVID–19, the treatment of a condition that may seriously complicate the treatment of COVID– 19, without amount, duration or scope limitations, if otherwise covered under the State child health plan (or waiver of such plan) and provided to beneficiaries without cost sharing, pursuant to section 2103(c)(11)(B) of the Act. Coverage for any non-pharmacological item or service described in section 2110(a) of the Act in CHIP that is medically necessary for treatment of COVID-19. Coverage for any drug or biological that is approved (or licensed) by the U.S. Food & Drug Administration (FDA) or authorized by the FDA under an Emergency Use Authorization (EUA) to treat or prevent COVID-19, consistent with the applicable authorizations.

Table of Contents State/Territory Name: Minnesota State Plan Amendment (SPA) #: 23-0030 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group November , 2023 Patrick Hultman, Deputy Medicaid Director Minnesota Department of Human Services 540 Cedar Street PO Box 64983 Saint Paul, MN 55164-0983 RE: MN 23-0030 Minnesota §1915(i) +ome and &ommunity-%ased 6ervices (HCBS) 6tate 3lan $mendment (SPA) Dear 3DWULFN Hultman: The Centers for Medicare & Medicaid Services (CMS) is approving the state’s request to amend its 1915(i) state plan home and community-based services (HCBS) benefit, transmittal number MN 23-0030. The effective date for this amendment is January 1, 2024. With this amendment, the state is changing the implementation date of the previously approved SPA MN 22-0017 as well as incorporating permanent funding for the moving expense allowance in Housing Stabilization – Transition Services. Enclosed are the following approved SPA pages that should be incorporated into your approved state plan: x Attachment 3.1-i: Page 19 – 28g x Supplement 3 to State Plan Attachment 4.19-B: Page 1 It is important to note that CMS’ approval of this change to the state’s 1915(i) HCBS state plan benefit solely addresses the state’s compliance with the applicable Medicaid authorities. CMS’ approval does not address the state’s independent and separate obligations under federal laws including, but not limited to, the Americans with Disabilities Act, Section 504 of the Rehabilitation Act, or the Supreme Court’s Olmstead decision. Guidance from the Department of Justice concerning compliance with the Americans with Disabilities Act and the Olmstead decision is available at http://www.ada.gov/olmstead/q&a olmstead.htm. MS CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

3DWULFN Hultman – Page 2 If you have any questions concerning this information, please contact me at (410) 786-7561. You may also contact Shawn Zimmerman at Shawn.Zimmerman@cms.hhs.gov or (410) 786-8291. Sincerely, George P. Failla, Jr., Director Division of HCBS Operations and Oversight cc: Lynell Sanderson, CMS Cynthia Nanes, CMS Deborah Benson, CMS Sandra Porter, CMS 3DW &DOODJKDQ, MN DHS

DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2.STATE 2 3 _ Q a 3 a MN -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT (e) XIX () XXI 4. PROPOSED EFFECTIVE DATE 1/1/2024 FORM APPROVED 0MB No. 0933-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) 1915(i), housing services & supports a FFY '24 $ 2 418 000 b. FFY '25 $ 3 546 000 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Attachment 3.1-i, pages 19 - 28g Attachment 4.19-B, Supplement 3, page 1 Attachment 3.1-i, pages 19- 28g 9. SUBJECT OF AMENDMENT Change in implementation date to provide a moving expense allowance to housing supports and services; permanent funding. 10. GOVERNOR'S REVIEW (Check One) (!) GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 11. SIGNATURE OF STATE AGENCY OFFICIAL 0 OTHER, AS SPECIFIED: 15. RETURN TO Patrick Hultman --------------1 Minnesota Department of Human Services 12. TYl--c:u l'lf\lVIC: Patrick Hultman Federal Relations Unit -------------------------t 540 Cedar Street, PO Box 64983 13. TITLE Saint Paul, MN 55164 Deputy Medicaid Director 14. DATE SUBMITTED September 12, 2023 16. DATE RECEIVED September 12, 2023 FOR CMS USE ONLY 17. DATE APPROVED November 1, 2023 PLAN APPROVED· ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL January 1, 2024 20. TYPED NAME OF APPROVING OFFICIAL George Failla, Jr. 22. REMARKS FORM CMS-179 (09/24) 19. SIGNATURE OF APPROVING 21 . TITLE OF APPROVING OFFICIAL Director, Division of HCBS Operations and Oversight Instructions on Back

State: Minnesota TN: 23-0030 Effective: January 1, 2024 § l 915(i) State plan HCBS App.: November 1, 2023 State plan Attachment 3 .1-i Page 19 Supersedes: 22-0017 1. State plan HCBS. (Complete thefollm1 ing table for each service. Copy table as needed): Service Specifications (Specify a service tit! e for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: I Housing Stabilization Se1vice- Transition Seivices Service Definition (Scope): Housing Stabilization - Transition Se1vices are community supports that help people plan for, find, and move to homes of their own in the community including: • • • • • • • • • • • Supporting the person in applying for benefits to afford their housing Identifying services and benefits that will support the person with housing instability Assisting the person with the housing search and application process Assisting the person with tenant screening and housing assessments Helping a person understand and develop a budget Helping recipients understand and negotiate a lease Helping the recipient meet and build a relationship with a prospective landlord Providing up to $3000 for ce1tain costs associated with moving, as described below Identifying resources to cover moving expenses that are not othe1wise covered under this se1vice Helping the person anange deposits Ensuring the new living anangement is safe and ready for move-in • Remote support when required to ensure their housing transition • Helping a person organize their move Remote support is real-time, two-way comm1mication between the provider and the paiiicipant. The service meets intennittent or 1mscheduled needs for suppolt for when a palticipant needs it to live and work in the most integrated setting, supplementing in person se1vice delive1y. Remote suppo1tis limited to check-ins (e.g. reminders, verbal cues, prompts) and consultations (e.g. counseling, problem solving) within the scope of housing stabilization se1vices. Remote suppoli may be utilized when it is chosen by the paiticipant as a method of se1vice delive1y. To meet the real-time, two-way exchange definition, remote support includes the following methods: telephone, secure video conferencing, and secure written electronic messaging, excluding e-mail and facsimile. All trnnsmitted electronic written messages must be retrievable for review. Providers must document the staff who delivered se1vices, the date of se1vice, the strut and end time of se1vice delive1y, length of time of service delive1y, method of contact, and place of se1vice (i.e. office or community) when remote suppolt se1vice delive1y occurs. Housing Stabilization-Transition Se1vices cannot duplicate other se1vices or assistance available to the person.

State: Minnesota TN: 23-0030 Effective: January L 2024 Moving Expenses § l 915(i) State plan HCBS App.: November 1, 2023 State plan Attachment 3 .1-i Page 20 Supersedes: 22-001 7 Moving Expenses are non-reoccuning and are limited to a maximum of $3000 annually for individuals receiving Housing Stabilization-Transition services and are transitioning out of Medicaid funded institutions or other provider-operated living anangements to a less restrictive living anangement in a p1ivate residence where the person is directly responsible for his or her own living expenses. For pmposes of this service component, "home" means a setting that a paiiicipant owns, rents, or leases that is not operated, owned or leased by a provider of services or suppo1ts. Moving Expenses include: • Applications, security deposits, and the cost of seeming documentation that is required to obtain a lease on an apaiiment or home • Essential household furnishings required to occupy and use a comnmnity domicile, including furniture, window coverings, food preparation items, and bed/bath linens • Set-up fees or deposits for utility or service access, including telephone, electricity, heating ai1d water • Services necessa1yfor the individual's health and safety such as pest eradication and one-time cleaning prior to occupancy • Necessa1y home accessibility adaptations Moving Expenses are furnished only to the extent that they are reasonable and necessaiy as determined through the service plan development process. These expenses must be clearly identified in the service plan. These items are not covered Moving Expenses: • Rent and mmtgage payments • Food • Clothing • Recreational and diversionaiy items. Recreational items include streaming devices, computers, televisions, cable television access, etc. • Items, expenses, or supports that duplicate any other se1vice • Costs of furnishing living anangements that are owned or leased by a provider where the provision of these items and se1vices are inherent to the se1vice they are already providing Providers must maintain all documentation of purchases and spending, including receipts, related to the person's Moving Expenses. Receipts must be uploaded to the Medicaid payer's claim system for review, approval, and to track costs separntely from other components of Housing Stabilization - Transition Se1vices. Additional needs-based crite1ia for receiving the se1vice, if applicable (specify):

State: Minnesota TN: 23-0030 Effective: January L 2024 § l 915(i) State plan HCBS App.: November 1, 2023 State plan Attachment 3 .1- i Page 21 Supersedes: 22-001 7 Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, se1vices available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies) : X Catego1ically needy (specify limits): Housing Stabilization - Transition Services are limited to 150 hours per transition. Additional hours beyond this threshold may be authorized by the Depaitment. Moving Expenses may be provided in a setting which does not comp01t with the settings requirements if the person will be moving into a setting which does compo1t with the settings requirements at move in. For persons residing in an institutional setting or another provider operated living atTangement prior to community transition ai1d 191 S(i) enrollment, se1vices may be furnished no more than 180 consecutive days prior to discharge and providers may not bill for Moving Expenses until the recipient has transitioned to a comrnllllity-based setting and is detennined eligible for Housing Stabilization - Transition Se1vices. [Housing Stabilization- Transition Services may be provided in a non-compliant setting if the person will be moving into a setting that is HCBS compliant at move in. for persons residing in an institutional setting or ai1other provider operated living a1Tai1gement p1io1 ~o community transition and 191 S(i) enrollment services may be furnished no more than 180 consecutive days p1ior to dischai·ge and providers may not bill for se1vices until the recipient has !transitioned to a commllllity-based setting. Under this circumstance, this se1vice will only be provided to individuals transitioning to a less restrictive setting, and for individuals trai1sitioning from provider-operated settings, the se1vice is only provided to those transitioning to a p1ivate residence where the individual will be directly responsible for his or her own living expense. ~ousing Stabilization -Trat1Sition Services ai·e not covered when a recipient is conclllTently receiving Housing Stabilization - Sustaining Se1vices. Moving Expenses Limitations: • Moving expense providers and/or their family members cannot sell goods and se1vices to recipients that are reimbursed through moving expense • Moving expenses cannot be used to purchase goods and services from a recipient's family member Limitations applicable to remote support service delive1y of Housing Stabilization - Transition Services: Remote supp01t cannot be used for more than one-half of direct service provided annually. Remote supp01t cannot have the effect of isolating a person or reducing their access to the commmlity. Ifremote support has such an effect, it is not allowed. A person has aright to refuse, stop, or suspend the use ofremote supp01t any time. • A person requiring a higher level of remote suppo1t annually may be granted an exception through a provider request for p1ior authorization for up to 75% of the direct se1vice proVISIOn. • Prior autho1ization for higher remote suppo11 is not required during the pe1iod of a federal or state public health emergency or disaster declai·ation affecting the person or the person's geographic area. • A person on Housing Stabilization - Transition Services may use remote support in a flexible manner that meet his/her/their needs within the total yeaily authorized units.

State: Minnesota TN: 23-0030 Effective: January 1, 2024 § l 915(i) State plan HCBS App.: November 1, 2023 State plan Attachment 3 .1-i Page 22 Supersedes: 22-0017 In order for providers to provide more than half of the direct service hours annually remotely, DHS must provide prior authorization. Providers request authorization through an Additional Remote Support Exception Request fo1m. Reasons an exception may be granted include: • a person engages more readily with the provider via remote means due to their disabling condition • The person is transient and difficult to physically locate but remains in contact remotely • The person works dm·ing regular business hours so remote support enables the person to remain employed and receive needed supp01ts to find or keep housing. • The person and provider are physically distant from one anotl1er and the person consents to additional remote support Providers need to outline remote suppoli delive1y methods agreed upon with the person. The housing suppoli plan must also document: • why those methods were chosen and detail why remote supp01t better meets the person's needs • how remote support will suppoli the person to live and work in the most integrated community settings • the needs that must be met through in-person suppoli • a plan for providing in-person and remote supports based on the person's needs to ensure their health and safety. The direct staff or caregiver responsible for responding to a person's health, safety, and other suppo11 needs through remote support must: • Respect and maintain the person's privacy at all times, including when the person is in settings typically used by the general public; • Respect and maintain the person's privacy at all times, including when scheduled or intermittent/as-needed supp01t includes responding to a person's health, safety, and other support needs for personal cares; • Ensure the use of enabling technology complies with relevant requirements under the Health Insurance Po1tability and Accom1tability Act (HIP AA). It is the provider's responsibility to develop record keeping systems which identify when a service was provided remotely, and track the number of remote hours utilized. Providers may not: • Bill direct suppo1t delivered remotely when the exchange between the service participant and the provider 1s social in nature; • Bill direct suppoli delivered remotely when real-time, two-way communication does not occur (e.g. leaving a voicemail; unanswered electronic messaging); • Bill for the use of Global Positioning System (OPS), Personal Emergency Response System (PERS) and video smveillance to provide remote check-ins or consultative supports.

State: Minnesota TN: 23-0030 Effective: Januaiy 1, 2024 § 191 S(i) State plan HCBS App.: November 1, 2023 State plai1 Attachment 3.1-i Page23 Supersedes: 22-0017; 18-0008; 21-0004 X Medically needy (specify limits): Housing Stabilization-Transition services are limited to 150 homs per transition. Additional homs beyond this threshold may be authorized by the Department. Moving Expenses may be provided in a setting which does not comport with the settings requirements if the person will be moving into a setting which does comport with the settings requirements at move in. For persons residing in an institutional setting or another provider operated living aITangement prior to community transition and 1915(i) emollment, services may be furnished no more than 180 consecutive days p1ior to discharge and providers may not bill for Moving Expenses until the recipient has transitioned to a community-based setting and is determined eligible for Housing Stabilization - Transition Services. Housing Stabilization- Transition Se1vices may be provided in a non-compliant setting if the person will be moving into a setting that is HCBS compliant at move in. For persons residing in a.ii institutional setting or another provider operated living atTangement prior to community transition and 1915(i) enrollment se1vices may be furnished no more than 180 consecutive days prior to dischai·ge and providers may not bill for se1vices until the recipient has transitioned to a community-based setting. Housing Stabilization -Transition Se1vices ai·e not covered when a recipient is conctmently receiving Housing Stabilization - Sustaining Se1vices. Moving Expenses Limitations: • Moving expense providers and/or their family members ca1mot sell goods and se1vices to recipients that are reimbursed through moving expense • Moving expenses cannot be used to purchase goods and services from a recipient's family member Limitations applicable to remote support se1vice delivery of Housing Stabilization - Transition Se1vices: • Remote support cannot be used for more than one-half of direct service provided aimually. Remote support cannot have the effect of isolating a person or reducing their access to the community. If remote support has such an effect, it is not allowed. A person has a right to refuse, stop, or suspend the use of remote supp01t any time. • A person requiling a higher level of remote suppo1t a.Illlually may be granted an exception through a provider request for p1ior authorization for up to 75% of the direct .. se1v1ce prov1s10n. • Prior autho1ization for higher remote supp01t is not required duril1g the period of a federal or state public health emergency or disaster declaration affecting the person or the person's geographic area. • A person on Housing Stabilization - Transition Se1vices may use remote suppolt in a flexible manner that meets his/her/their needs within the total yearly authorized mlits.

24 State: Minnesota § 191 S(i) State plan HCBS State plan Attachment 3.1-i TN: 23-0030 Page 24 Effective: Januarv 1, 2024 App.: November 1, 2023 Supersedes: 22-0017; 18-0008; 21-0004 In order for providers to provide more than half of the direct service hours annually remotely, DHS must provide prior authorization. Providers request authorization through an Additional Remote Support Exception Request fonn. Reasons an exception may be granted include: • a person engages more readily with the provider via remote means due to their disabling condition • The person is transient and difficult to physically locate but remains in contact remotely • The person works during regular business hours so remote suppmt enables the person to remain employed and receive needed supports to find or keep housing. • The person and provider are physically distant from one another and the person consents to additional remote support Providers need to outline remote support delive1y methods agreed upon with the person. The housing support plan must also document: • why those methods were chosen and detail why remote suppmt better meets the person's needs • how remote suppoli will suppo1t the person to live and work in the most integrated community settings • the needs that must be met through in-person suppmt • a plan for providing in-person and remote supports based on the person's needs to ensure their health and safety. The direct staff or caregiver responsible for responding to a person's health, safety, and other support needs through remote suppmt must • Respect and maintain the person's privacy at all times, including when the person is in settings typically used by the general public; • Respect and maintain the person's privacy at all times, including when scheduled or intermittent/as-needed suppoli includes responding to a person's health, safety, and other support needs for personal cares; • Ensure the use of enabling technology complies with relevant requirements under the Health Insurance Portability and Accountability Act (HIP AA). It is the provider's responsibility to develop record keeping systems which identify when a service was provided remotely, and track the number of remote hours utilized. Providers may not: • Bill direct suppmt delivered remotely when the exchange between the service pa1ticipant and the provider 1s social in nature; • Bill direct support delivered remotely when real-time, two-way commllllication does not occur ( e.g. leaving a voicemail; unanswered electrnnic messaging); • Bill for the use of Global Positioning System (GPS), Personal Emergency Response System (PERS) and video surveillance to provide remote check-ins or consultative suppmts.

25 State: Minnesota § 191 S(i) State plan HCBS App.: November 1, 2023 State plan Attachment 3 .1-i Page 25 Supersedes: 22-0017; 18-0008; 21-0004 TN: 23-0030 Effective: Janua1y 1, 2024 Provider Type (Specify): License Certificatior Other Standard (Specify). (Specify): (Specify}: Agency: agencies that meet the Individuals providing housing housing stabilization se1vice stabilization services must standards have: • Knowledge of local Individual: Individuals that meet housing resources. the housing stabilization se1vice • Completed housing standards stabilization se1vices training approved by the Commissioner. • Completed mandated rep01ter training which includes training on vulnerable adult law. Additionally, providers of housing stabilization se1vices must pass a criminal background study. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type Entity Responsible for Frequency ofVe1ification (Specify): Ve1ification (Specify): (Specijj): Agency: Agencies that Minnesota Department Eve1y five years meet the Housing of Human Se1vices Stabilization service standards Individual: h1dividuals Minnesota Depaitment Eve1y five years that meet the housing of Human Se1vices stabilization service standai·ds Service Delivery Method. (Check each that applies): □ Paiticipant-directed X Provider managed

State: Minnesota 1N: 23-0030 Effective: Januaiy I, 2024 §1915(i) State plan HCBS App.: November L 2023 State plan Attachment 3.1-i Page 26 supersedes· 22-0017· J8-00Q8· 21-0004 Service Spedfications (Specify a se1-i ice title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Se1vice Title: I Housing Stabilization Service - Sustaining Se1vice Definition (Scope): Community suppo1ts that help a person to maintain living in their own home in the community including: • Developing, updating and modifying the housing support and crisis plan on are gular basis • Prevention and early identification of behaviors that may jeopardize continued housing • Education and training on roles, rights, and responsibilities of the tenant and prope1ty manager • Coaching to develop and maintain key relationships with propeliy managers and neighbors • Advocacy with community resources to prevent eviction when housing is at risk • Assistance with the housing recertification processes • Continuing training on being a good tenant, lease compliance, and household management • Supp01ting the person to apply for benefits to retain housing • Supp01ting the person to understand and maintain income and benefits to retain housing • Supporting the building of natural housing supports and resources in the community • Remote support when required to help the person retain their housing Remote supp01t is real-time, two-way communication between the provider and the pa1ticipant The service meets inte1mittent or unscheduled needs for suppo1t for when a patticipant needs i1 to live and work in the most integrated setting, supplementing in person service delivery. Remote support is limited to check-ins (e.g. reminders, verbal cues, prnmpts) and consultations (e.g. counseling, problem solving) within the scope of housing stabilization services. Remote suppoti may be utilized when it is chosen by the paiticipant as a method of service delivery. To meet the real-time, two-way exchange definition, remote support includes the following methods: telephone, secure video conferencing, and secure written electrnnic messaging, excluding e-mail and facsimile. All transmitted electrnnic written messages must be retrievable for review. Providers must document the staff who delivered services, the date of se1vice, the start and end time of se1vice delive1y, length oftime of se1vice delive1y, method of contact, and place of se1vice (i.e. office or community) when remote suppo1t se1vice delive1y occurs. Sustaining services do not include: • Deposits • Food • Furnishings • Rent • Utilities • Room and boaid • Moving expenses Sustaining se1vices cannot duplicate other se1vices or assistance available to the person.

State: Minnesota 1N: 23-0030 Effective: Januaiy I, 2024 §1915(i) State plan HCBS App.: November I, 2023 State plan Attachment 3.1-i Page 27 Sunersedes- 22-0017; 18-0008; 21-0004 Add1t10nal needs-based cntena tor rece1vmg tile service, 11 appbcable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): X Categoncally needy (specify limits): ttousm2 ~taomzanon-~ustamm2 sernces are 1rmuea to DU nours annually. Additional hours beyond this threshold may be authorized by the Department. Limitations applicable to remote support service delive1y of housing stabilization se1V1ces: • Remote support cannot be used for more than one-half of direct service provided annually. Remote support cannot have the effect of isolating a person or reducing their access to the community. If remote suppmt has such an effect, it is not allowed. A person has a right to refuse, stop, or suspend the use of remote suppo11 at any time. • A person requiring a higher level of remote support annually may be granted an exception through a provider request for prior authorization for up to 75% of the direct service provision. • Prior authorization for higher remote support is not required during the period of a federal or state public health emergency or disaster declaration affecting the person or the person's geographic a1ea. • A person on Sustaining services may use remote suppo1t in a flexible mam1er that meets his/her/their needs within the total yearly authorized units. In order for providers to provide more than half of the direct service hours annually remotely, DHS must provide authorization. Providers request authorization through an Additional Remote Support Exception Request fonn. Reasons an exception may be granted include: • a person engages more readily with the provider via remote means due to their disabling condition • The person is transient and difficult to physically locate but remains in contact remotely • The person works during regular business hours so remote support enables the person to remain employed and receive needed supports to find or keep housing. • The person and provider are physically distant from one another and the person consents to additional remote support Providers need to outline remote suppoti delive1y methods agreed upon with the person. The housing suppo1i plan must also document: • why those methods were chosen and detail why remote support better meets the person's needs • how remote suppmt will suppmt the person to live and work in the most integrated community settings

State: Minnesota 1N: 23-0030 Effective: Januaiy I, 2024 §1915(i) State plan HCBS Aoo.: November I, 2023 State plan Attachment 3.1-i Page 28 Sunersedes- 22-0017: 18-0008· 21-0004 X • the needs that must be met through m-person support • a plan for providing in-person and remote supp mis based on the person's needs to ensure their health and safety. The direct staff or caregiver responsible for responding to a person's health, safety, and other support needs through remote suppmt must: • Respect and maintain the person's privacy at all times, including when the person is in settings typically used by the general public; • Respect and maintain the person's privacy at all times, including when scheduled or intennittent/as-needed support includes responding to a person's health, safety, and other suppmi needs for personal cares • Ensure the use of enabling technology complies with relevant requirements under the Health Insurance Pmiability and Accountability Act (HIPAA). It is the provider's responsibility to develop record keeping systems which identify when a service was provided remotely, and trnck the number of remote hours utilized. Providers may not: • Bill direct support delivered remotely when the exchange between the service pa1iicipant and the provider is social in nature; • Bill direct support delivered remotely when real-time, two-way communication does not occur (e.g. leaving a voicemail; unanswered electronic messaging); • Bill for the use of Global Positioning System (GPS), Personal Emergency Response System (PERS) and video surveillance to provide remote check-ins or consultative suppmts. Medically needy (specify limits):

State: Minnesota TN: 23-0030 Effective: January 1. 2024 § 191 S(i) State plan HCBS App.: November 1, 2023 State plan Attachment 3.1-i Page 28a Supersedes: 22-0017: 18-0008: 21-0004 Housing Stabilization-Sustaining services are lnmted to 150 hours annually. Additional homs beyond this threshold may be authorized by the Department. Limitations applicable to remote support service delive1y of housing stabilization service: • • • Remote support cannot be used for more than one-half of direct service provided annually. Remote support cam1ot have the effect of isolating a person or reducing their access to the community. If remote supp01i has such an effect, it is not allowed. A person has a right to refuse, stop, or suspend the use of remote support at any time. A person requiring a higher level of remote supp011 annually may be granted an exception through a provider request for prior authorization for up to 75% of the direct service provision. Prior authorization for higher remote supp01i is not required during the period of a federal or state public health emergency or disaster declaration affecting the person or the person's geographic area. • A person on sustaining services may use remote support in a flexible manner that meets his/her/their needs within the total yearly authorized units. In order for providers to provide more than half of the direct service hours annually remotely, DHS must provide authorization. Providers request authorization through an Additional Remote Suppmi Exception Request f01m. Reasons an exception may be granted include: • a person engages more readily with the provider via remote means due to their disabling condition • The person is transient and difficult to physically locate but remains in contact remotely • The person works during regula1· business hours so remote suppo11 enables the person to remain employed and receive needed supports to find or keep housing. • The person and provider are physically distant from one another and the person consents to additional remote suppo11. Providers need to outline remote support delive1y methods agreed upon with the person. The housing support plan must also document: • why those methods were chosen and detail why remote suppo1i better meets the person's needs, • how remote support will suppmi the person to live and work in the most integrated commrn1ity settings, • the needs that must be met through in-person suppmi • a plan for providing in-person and remote supports based on the person's needs to ensure their health and safety. The direct staff or caregiver responsible for responding to a person's health, safety, and other suppmi needs through remote suppmi must: • Respect and maintain the person's privacy at all times, including when the person is in settings typically used by the general public;

State: Minnesota § 191 S(i) State plan HCBS State plan Attachment 3.1-i TN: 23-0030 Page 28b Effective: Januarv L 2024 Aoo.: November 1, 2023 Sune.rsedes: 22-0017: 18-0008: 21-0004 • Respect and maintain the person's privacy at all times, including when scheduled or intennittent/as-needed suppmt includes responding to a person's health, safety, and other support needs for personal cares • Ensme the use of enabling technology complies with relevant requirements under the Health Insurance Pmtability and Accountability Act (HIP AA). It is the provider's responsibility to develop record keeping systems which identify when a service was provided remotely, and track the number of remote hours utilized. • Providers may not: o Bill direct s1.1ppo1t deldiveJ·ed remodtely when the exchange between the service part c pant an the prov1 er 1s soc a rn nature; o Bill direct suppmt delivered remotely when real-time, two-way communication does not occur ( e.g. leaving a voicemail; unanswered electronic messaging); o Bill for the use of Global Positioning System (GPS), Personal Emergency Response System (PERS) and video surveillance to provide remote o check-ins or consultative supports.

State: Minnesota TN: 23-0030 Effective: January 1, 2024 § 191 S(i) State plan HCBS App.: November 1, 2023 State plan Attachment 3 .1-i Page 28c Supersedes: 22-0017: 18-0008: 21-0004 Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License Ce1tificati01 Other Standard (Specify): (Specify): (Specify): Agency: agencies that meet the Agency providers of housing stabilization service housing stabilization standards se1vices must assure all staff providing the service have: • Knowledge oflocal housing resources. • Completed housing stabilization service training approved by the Commissioner. • Completed mandated repoiter training which includes training on Vulnerable Adult law. Additionally providers of Housing stabilization se1vices must apply the standards in Minnesota Statutes, chapter 245C concerning criminal background studies. Individual: Individuals that meet the Individuals providing housing stabilization se1vice housing stabilization standards services must have: • Knowledge oflocal housing resources. • Completed housing stabilization services training approved by the Commissioner. • Completed mandated repo1ter training which includes training on vulnerable adult law. Additionally, providers of housing stabilization se1vices must pass a c1iminal background study.

State: Minnesota TN: 23-0030 Effective: January 1, 2024 § 191 S(i) State plan HCBS App.: November 1, 2023 State plan Attachment 3 .1-i Page28d Supersedes: 22-0017: 18-0008: 21-0004 Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Ve1ification Frequency of (Specify): Verification (Specify}: Agency: Agencies that meet the Minnesota Department of Human Eve1yfive Housing Stabilization service Services years standards Individual: Individuals that meet the Minnesota Department of Human Eve1yfive housing stabilization service Services years standards Service Delivery Method. (Check each that applies}: □ Pmticipant-directed X Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Se1vice Title: I Housing Consultation Services Se1vice Definition (Scope): Housing Consultation: planning services that are person-centered and assist a person with the creation of the person-centered plan. Recipients may also receive refe1rnls to other needed services and supp01ts based on the person-centered plan. The consultant monitors and updates the plan annually or more frequently if the person requests a plan change or expe1iences a change in circumstance. This service shall be separate and distinct from all other se1vices and shall not duplicate other se1vices or assistance available to the pa11icipant. Housing consultation se1vices may only be billed after approval of the plan by the Department. Systems edits will be in place to prevent the payment of targeted case management services in the same month in which housing consultations se1vices are billed. Additional needs-based c1ite1ia for receiving the seivice, if applicable (specify}:

State: Minnesota TN: 23-0030 Effective: January 1, 2024 § 191 S(i) State plan HCBS App.: November 1, 2023 State plan Attachment 3 .1-i Page 28e Supersedes: 22-0017: 18-0008: 21-0004 Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and se1vices must be equal for any individual within a group. States must also separately address standard state plan se1vice questions related to sufficiency of se1vices. (Choose each that applies): X Categ01ically needy (specify limits): Housing consultation services are available one time, annually. Additional sessions may be authorized by the Department if the recipient becomes homeless or experiences a significant change in a condition that impacts their housing, or when a person requests an update or change to their plan. To avoid conflict of interest, an individual cannot receive housing consultation services and housing stabilization se1vices from the same provider. Recipient must be living in, or planning to transition to a new home in a community- based setting. These se1vices may be provided in a non-compliant setting if the person will be moving into a setting that is HCBS compliant at move in. For persons residing in an institutional setting, providers may not bill for se1vices until the recipient has trnnsitioned to a community-based setting. Remote suppott- Housing Consultation • Remote suppott: A real-time, two-way communication between the provider and the person. For housing consultation, remote support can only be performed through telephone or secure video conferencing. • Providers must document that the plan was completed remotely and why it was a remote planning session. The case notes must also identify the staff who delivered se1vices, the date of se1vice, the method of contact and place of service (i.e. office or community). X Medically needy (specify limits):

State: Minnesota TN: 23-0030 Effective: January 1, 2024 § 191 S(i) State plan HCBS App.: November 1, 2023 State plan Attachment 3 .1-i Page 281" Supersedes: 22-0017: 18-0008: 21-0004 Housing consultation services are available one time, annually. Additional sessions may be authorized by the Department if the recipient becomes homeless or experiences a significant change in a condition that impacts their housing, or when a person requests an update or change to their plan. To avoid conflict of interest, an individual cannot receive housing consultation services and housing stabilization se1vices from the same provider. Recipient must be living in, or planning to trnnsition to a new home in a community- based setting. These se1vices may be provided in a non-compliant setting if the person will be moving into a setting that is HCBS compliant at move in. For persons residing in an institutional setting, providers may not bill for se1vices until the recipient has tJansitioned to a community-based setting. Remote suppo1t- Housing Consultation • Remote support: A real-time, two-way communication between the prnvider and the person. For housing consultation, remote support can only be perfmmed through telephone or secure video conferencing. • Providers must document that the plan was completed remotely and why it was a remote planning session. The case notes must also identify the staff who delivered se1vices, the date of se1vice, the metl1od of contact and place of service (i.e. office or commUiiity). Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type License Ce1tifi.cation Other Standard (Specify) : (Specify): (Specify): (Specify): Agency: Agencies that meet the housing consultation service standards Individual: Individuals that meet the housing Agency providers of Housing Consultation se1vices must assure staff providing the se1vice have: • Knowledge of local housing resources and must not have a direct or indirect financial interest in the property or housing the participant selects. • Completed trnirung approved by the Commissioner. Additionally, providers of Housing Consultation se1vices must apply the standards in Minnesota Statutes, chapter 245C concerning c1iminal background studies. Individual providers of housing consultation se1vices must assure they have:

State: Minnesota TN: 23--0030 Effective: Januruy 1, 2024 consultation se1vice standards § l 9 l 5(i) State plan HCBS App.: November 1, 2023 State plan Attachment 3 .1-i: Page28g Supersedes: 22-0017; 18-0008; 21-0004 • Knowledge of local housing resources and must not have a direct or indirect financial interest in the property or housing the paiticipant selects. • Completed training approved by the Commissioner. Additionally providers of Housing Consultation se1vices must pass a criminal background study. Verification of Provider Qualifications (For each provider type listed ab01 e. Copy rows as needed) : Provider Type Entity Responsible for Verification Frequency of Ve1ification (Specify): (Specify): (Specify): Agency: Minnesota Department of Human Se1vices Eve1y five years Agencies that meet the housing consultation service standards Individual: Minnesota Depa1tment of Human Se1vices Eve1y five years Individuals that meet the housing consultation service standards Service Delivery Method. (Check each that applies): □I Participant-directed I X I Provider managed

State: Minnesota TN: 23-0030 § l 9 l 5(i) State plru.1 HCBS Supplement 3 to State plan Attachment 4.19-B: Page 1 Supersedes: 22-0017; 18-0008 Effective: Januru.y 1, 2024 App.: November 1, 2023 Methods and Standards for Establishing Payment Rates 1. Services Provided nder Section 1915(i) of the Social Security Act. For each optional se1vice, desc1ibe the methods and standru.·ds used to set the associated payment rate. (Check each that applies, and describe methods and standards to set rates): □ HCBS Case Management □ HCBS Homemaker □ HCB S Horne Health Aide □ HCBS Personal Cru.·e □ HCBS Adult Day Health □ HCBS Habilitation □ HCBS Respite Care For Individuals with Chronic Mental Illness, the following services: □ HCBS Day Treatment or Other Partial Hospitalization Services □ HCBS Psychosocial Rehabilitation □ HCBS Clinic Services (whether or not furnished in a facility for CMI) X Other Services (specify below) All public, private and tribal ( defined as an IHS or 638 facility) providers arn reimbursed as described below: Effective July 1, 2020, housing stabilization- transition se1vices are paid the lower of the submitted charge, or $17 .1 7 per 15-minute lmit. Effective August 1, 2023 Januaiy 1, 2024, moving expenses are reimbursed at ma1·ket rates. Ma1·ket rates arn purchased at the usual retail price charged to the community. Effective July 1, 2020, housing stabilization services - sustaining are paid the lower of the submitted charge, or $17 .17 per 15-minute unit. Effective July 1, 2020, consultation services are paid the lower of the submitted charge, or $174.22 per session.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages MN-23-0034-CHIP Minnesota

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

January 2, 2024

Julie Marquardt Acting Medicaid Director State of Minnesota, Department of Human Services 540 Cedar Street St. Paul, MN 55167‐0983

Dear Julie Marquardt:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number MN-23-0034-CHIP, submitted on December 18, 2023, has been approved. Through this SPA, Minnesota has demonstrated compliance with the longstanding requirement at 42 CFR § 457.410(b)(2) and 457.520(b)(4) to cover age-appropriate vaccines. This SPA has an effective date of October 1, 2023.

Current regulations at 42 CFR § 457.410(b)(2) and 457.520(b)(4) require states to cover age- appropriate vaccines and their administration in accordance with the recommendations of the Advisory Committee on Immunization Practices (ACIP) without cost sharing. The state provided the necessary assurances to demonstrate compliance with this requirement.

Your Project Officer is Chanelle Parkar. She is available to answer your questions concerning this amendment and other CHIP-related matters. Her contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: 667-290-8798

E-mail: Chanelle.Parkar@cms.hhs.gov

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

Sincerely,

Sarah deLone Director /Signed by Sarah deLone/

Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements 1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70): Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI. 1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. X A combination of both of the above. (Section 2101(a)(2)) 1.1.DS The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5)) 1.2. X Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) 1.3. X Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications). 1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date. Original Plan Effective Date: September 30, 1998 Implementation Date: September 30, 1998 1.4- TC SPA #MN-23-0025 Purpose of SPA: The state is assuring that it covers age-appropriate vaccines and their administrative costs, without cost sharing. Proposed effective date: October 1, 2023 Proposed implementation date: October 1, 2023 Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. No consultation was conducted because Tribes are not affected by this state plan amendment. MN 23-0025: Approval Date: __________ Effective Date: October 1, 2023 6.5-Vaccine coverages Guidance: States are required to provide coverage for age-appropriate vaccines and their administration, without cost sharing. States that elect to cover children under the State plan (indicated in Section 4.1) should check box 6.5.1 States that elect to cover pregnant individuals under the State plan should also check box 6.5.2. States that elect to cover the from-conception-to-end-of-pregnancy population (previously referred to as the “unborn”) option under the State plan should also check box 6.5.3. 6.5.1- Vaccine coverage for targeted-low-income children. The State provides coverage for age-appropriate vaccines and their administration in accordance with the recommendations of the Advisory Committee on Immunization Practices (ACIP),

without cost sharing. (Section 2103(c)(1)(D)) (42CFR 457.410(b)(2) and 457.520(b)(4)). 6.5.2- Vaccine coverage for targeted-low-income pregnant individuals. The State provides coverage for approved adult vaccines recommended by the ACIP, and their administration, without cost sharing. (SHO # 23-003, issued June 27, 2023); (Section 2103(c)(12)) 6.5.3-Vaccine coverage for from-conception-to-end-of-pregnancy population option. X The state provides coverage for age appropriate (child or adult) vaccines and their administration in accordance with the recommendations of the ACIP, without cost- sharing, to benefit the unborn child.

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Minnesota MN-24-0026

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

August 1, 2024

John Connolly Assistant Commissioner Health Care/State Medicaid Director MN Department of Human Services Health Care Administration State of Minnesota, Department of Human Services St. Paul, MN 55167-0983

Dear Director Connolly:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), MN-24- 0026, submitted on June 27, 2024, has been approved. This SPA has an effective date of January 1, 2024.

Through this SPA, Minnesota provides 12 months of continuous eligibility (CE) coverage to individuals enrolled in its separate CHIP, pursuant to section 5112 of the Consolidated Appropriations Act, 2023 (CAA, 2023). Section 5112 of the CAA, 2023 amended titles XIX and XXI of the Social Security Act to require that states provide 12 months of CE for children under the age of 19 in Medicaid and CHIP. In Minnesota, this is the from-conception-to-end-of-pregnancy (FCEP) population. A copy of the approved CS27 state plan page is attached and is to be incorporated into the state’s approved CHIP state plan.

Your Project Officer is Chanelle Parkar. She is available to answer your questions concerning this amendment and other CHIP-related matters. Her contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: 667-290-8798

E-mail: Chanelle.Parkar@cms.hhs.gov

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

Sincerely,

Sarah deLone Director /Signed by Sarah deLone/

Page 1 of 2 CHIP Eligibility State Name: Minnesota OMB Control Number: 0938-1148 Transmittal Number: MN - 24 - 0026 Separate Child Health Insurance Program General Eligibility - Continuous Eligibility CS27 2107(e)(1)(K) of the SSA and 42 CFR 457.342 and 435.926; 2107(e)(1)(J) and 1902(e)(16) of the SSA Mandatory 12-Month Postpartum Continuous Eligibility in CHIP for States Electing This Option in Medicaid

At state option in Medicaid, states may elect to provide continuous eligibility for an individual’s 12-month postpartum period consistent with section 1902(e)(16) of the SSA. If elected under Medicaid, states are required to provide the same continuous eligibility and extended postpartum period for pregnant individuals in its separate CHIP. A separate CHIP cannot implement this option if not also elected under the Medicaid state plan. State elected the Medicaid option to provide continuous eligibility through the 12- month postpartum period Mandatory Continuous Eligibility for Children

The CHIP Agency must provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, for a 12-month continuous eligibility period. Consistent with section 2107(e)(1)(K) of the SSA, the state assures that continuous eligibility is provided to its targeted low-income children for a duration of 12 months, regardless of any changes in circumstances, unless: The child attains age 19. The child or child's representative requests voluntary disenrollment. The child is no longer a resident of the state. The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative. The child dies. The child becomes eligible for Medicaid. The state elects to provide coverage to the from-conception-to-end-of-pregnancy (FCEP) population (otherwise known as the "unborn"). Yes The state assures continuous eligibility for the FCEP population is provided in the same manner as continuous eligibility for other targeted low-income children, except for the duration of the continuous eligibility period. The duration of continuous eligibility for the FCEP population depends on whether a state enrolls the birthing parent into Medicaid for coverage of labor and delivery or pays for the delivery under CHIP. The state conducts at least one of the following actions upon birth of the child: CHIP pays for labor and delivery and the state screens the child for potential eligibility for Medicaid. Yes

Page 2 of 2 CHIP Eligibility Emergency Medicaid pays for labor and delivery and the state deems the newborn eligible for Medicaid and ends the continuous eligibility period in CHIP. No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20240322

_____________________________________________________________________________ Table of Contents State/Territory Name: Minnesota State Plan Amendments (SPA) #: MN-CHIPSPA#4 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan

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

7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

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

Ms. Ann Berg

Deputy Medicaid Director

Minnesota Department of Human Services NOV 19 2013 PO Box 64983

St. Paul, MN 55164-0983

Dear Ms. Berg:

This letter is to inform you that Minnesota’s title XXI Children’s Health Insurance Program (CHIP) State plan amendment (SPA) number 4 submitted on September 16, 2009, with additional information provided on November 23, 2010, May 21, 2010, and November 4, 2013 has been approved.

This SPA will allow Minnesota to implement a Health Services Initiative to provide postpartum services for women whose newborns had been covered as targeted low income children from conception to birth. While this SPA has a retroactive effective date of July 1, 2009, the state has been informed that, based on the 2-year timely filing rule, Federal Medical Assistance Percentage (FMAP) is only available for those services provided from FFY 2011 to date.

The state shall ensure that remaining title XXI funding, within the state’s 10 percent limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of this HSI to the administration of the CHIP program.

Your new title XXI project officer is Ms. Kathy Cuneo. She is available to answer questions concerning this amendment. Ms. Cuneo’s contact information is as follows:

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

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

Telephone: (410) 786-5913

Facsimile: (410) 786-5882

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

Official communications regarding program matters should be sent simultaneously to Ms. Cuneo and to Ms. Verlon Johnson, Associate Regional Administrator in our Chicago Regional Office.

/ Cindy Mann/

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

1 Effective Date:

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

Preamble

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

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

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

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

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

State/Territory:

MINNESOTA

(Name of State/Territory)

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

______/s/, Ann Berg, Deputy Medicaid Director, September 16, 2009____________ (Signature of Governor, or designee, of State/Territory, Date Signed)

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

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

Name: Brian Osberg

Position/Title: Medicaid & Health Care Purchasing Director Name: Billie Jo Zilinski

Position/Title: Assistant Commissioner, Health Care Name: Wendy Dwyer

Position/Title: Chief Operations Officer, Financial

Management & Operations Name: Ann Berg

Position/Title: Deputy Medicaid Director

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this Form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

2 Effective Date:

Approval Date:

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

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

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

1.1.1

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

1.1.2.

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

1.1.3.

A combination of both of the above.

1.2.

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

1.3.

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

1.4.

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

Effective date: __________

Implementation date: July 1, 2009

3 Effective Date:

Approval Date:

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

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

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

OVERVIEW OF HEALTH COVERAGE IN MINNESOTA

Historically, Minnesota has had one of the lowest rates of uninsurance in the country. Of the 4,649,596 individuals in Minnesota in 19961, approximately 6 percent to 9 percent, or between 280,000 and 420,000, lacked health coverage at any point in time during the year.2 While estimates of uninsurance in Minnesota vary by source, all surveys indicate that Minnesota’s rate of uninsurance has remained stable over the course of the 1990s, in contrast to the experience nationally, where the numbers of uninsured have continued to climb.3

Sources of Health Insurance Coverage for Minnesotans

Data from the Minnesota Department of Health shows the distribution of Minnesota’s population by primary source of health insurance coverage.4 In 1996, two-thirds (67%) of Minnesotans received their primary health insurance coverage through a private sector source, either from an employer or individually purchased. Public program enrollment, including Medicare, accounted for approximately 25 percent of Minnesotans, and estimates of the uninsured ranged from 6 percent to 9 percent.

1 U.S. Bureau of the Census, Estimates of the Population of State: Annual Time Series, July 1, 1990 to July 1, 1997, press release of December 31, 1997. 2 Estimates of the uninsured in Minnesota differ by the source of the estimates. Surveys conducted by the University of Minnesota in 1990 and 1995 show the rate of point-in-time uninsurance to be 6.0 percent, while the Current Population Survey (using three- year average data) shows the rate to be approximately 9.2 percent. 3 The Current Population Survey (CPS) indicates that rates of uninsurance nationally have risen from 13.6 percent in 1990 (three- year average rate) to 15.4 percent in 1996. CPS data shows Minnesota’s rate of uninsurance to be stable over this same time period at approximately 9.2 percent. 4 Some individuals are enrolled in more than one type of health insurance coverage. For example, many Medicare enrollees also are enrolled in Minnesota’s Medical Assistance program. The information presented in Table 1 counts individuals only once, however, and assigns them to coverage based on the primary payer for coverage. 4 Effective Date:

Approval Date:

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

Table 1: Primary Source of Health Insurance Coverage for Minnesotans, 1996

Source Percent Covered Employer-Based 62%-65% Individual 5% Medical Assistance 8% MinnesotaCare 2% Medicare 14% Other Public 1% Uninsured 6%-9%

Note: Numbers may not total to 100% due to rounding. Source: Minnesota Department of Health.

Excluding Minnesota’s elderly, nearly all of whom have Medicare as their primary source of insurance coverage, shows that approximately three-quarters (76%-79%) of non-elderly Minnesotans receive health coverage through a private sector source, with 15% receiving coverage through a public program (either Medical Assistance, MinnesotaCare, Medicare, or another public program). Between 7 percent and 10 percent of non-elderly Minnesotans are uninsured at any point in time.