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

Effective Date: January 2005

Approval Date: June 2006 1

OMB #: 0938-0707 Exp. Date:

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

Preamble

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

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

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

Form CMS-R-211

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

Effective Date: January 2005

Approval Date: June 2006 2

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

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

State/Territory:_____MISSISSIPPI___________________________________ (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/ Haley Barbour_______________________ 3-15-06 (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: Robert L. Robinson, DBA

Position/Title: Executive Director

Name: Maria D. Morris

Position/Title: Bureau Director/CHIP

Name: David Maatallah Position/Title: Office Director/ Finance &Accounts

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

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

Effective Date: January 2005 Approval Date: June 2006 3 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

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

1.1.1

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

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

1.1.3. 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):

Date Plan submitted:

July 29,1998 Date Plan effective:

July 1, 1998 Date Amendment #1 submitted: August 1, 1998 Date Amendment #1 effective: January 1, 2000 Date Amendment #2 submitted: September 22, 1999 Date Amendment #2 effective: January 1, 2000 Date Amendment #3 submitted: July 6, 2000 Date Amendment #3 effective: October 1, 2000 Date Amendment #4 submitted: July 3, 2001 Date Amendment #4 effective: July 1, 2001 Date Amendment #5 submitted: September 30, 2002 Date Amendment #5 effective: January 1, 2005 Date Amendment #6 submitted: December 29, 2005 Date Amendment #6 effective: January 1, 2005

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

Effective Date: January 2005 Approval Date: June 2006 4 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))

Demographics

According to latest available census reports, Mississippi's population is 2,844,658 (2000 Census).

According to the Behavorial Risk Factor Surveillance System, 16% of Mississippi's population is currently under 100% of the Federal Poverty Level, or approximately 340,479. Twenty-one percent of the families in Mississippi have children under age 18.

According to the 2000 Census reports, there are 873,214 (30.7%) children ages less than 19 in the State of Mississippi. See Attachment A for breakdown by county.

Medicaid Eligibles

According to 1998 reports generated by the Division of Medicaid’s decision support system, Mississippi Medicaid Information Retrieval System (MMIRS), there are 223,184 Mississippi children ages less than 19 currently enrolled in Medicaid. See Attachment B for breakdown by county.

Based on Heritage Foundation estimates combined with the State's estimates, there could be as many as 41,751 children less than 19 years of age eligible for Medicaid who are currently not enrolled as of 1998. See Attachment A for breakdown by county. These 41,751 children are targeted as part of an outreach initiative to find and enroll Medicaid eligible children under Title XIX.

CHIP

Mississippi originally implemented its SCHIP in July 1998 with a Medicaid expansion program for children 15-18 years at 100% FPL. This phase of the program ended as of October 01, 2002. To date, the State's CHIP targets all children in the state below age 19 who are below 200% FPL, not eligible for Medicaid coverage, and have no other health coverage. According to Census and MMIRS data, it was estimated there are approximately 65,000- 85,000 uninsured children in the state

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

Effective Date: January 2005 Approval Date: June 2006 5 below age 19 who are below 200% FPL and do not qualify for Medicaid. The goal is to assess these children for CHIP eligibility under a health coverage package. As of August 2005, over 66,000 children are enrolled in CHIP.

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

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

Medicaid is the only other public health insurance program in the State of Mississippi for children. Health services are provided in Mississippi to uninsured and Medicaid enrolled children by private physicians, 82 Mississippi County Health Department clinics operating at 110 sites, 22 FQHC’s, newly-funded school health nurses, and several Indian Health Service Clinics. In addition, the Children's Medical Program provides specialty care to uninsured and Medicaid enrolled children with special health care needs. The Department of Mental Health (DMH) provides mental health services to children through their Community Mental Health Clinics on a sliding scale fee arrangement based upon the patient's declared income. These entities currently identify and help enroll children who are eligible for Medicaid coverage and will be used to identify and enroll non-covered children who are eligible to participate in the CHIP as well as the Medicaid program. The Department of Education (DOE) has signed a memorandum of understanding with the Division of Medicaid (DOM) to assist with the identification and enrollment for CHIP. Program information presentations are provided on an on-going basis to schools and Head Starts in the state, inviting families to apply for health benefits (Medicaid or CHIP). Applications, pamphlets, flyers, and posters are being widely distributed together with informational brochures in Spanish and Vietnamese, as well as English.

Mississippi State Health Department

This agency administers services and programs for Medicaid recipients and uninsured families and children in maternal-child health, environmental health (including lead screening for children under the Medicaid Early, Periodic Screening Diagnostic Treatment (EPSDT) program, family planning, newborn genetic screening, well child health services, immunizations, and tuberculosis control. The Health Department operates a county health department system of 110 sites, 18 regional home health offices and 92 WIC distribution centers. The Health Department partners with the Division of Medicaid in providing targeted case management services for infants and toddlers and for EPSDT children and perinatal high-risk pregnancy case management services. This agency is an integral part of the outreach system for finding Medicaid and CHIP eligible children.

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

Effective Date: January 2005 Approval Date: June 2006 6

Mississippi Department of Human Services (DHS)

This agency provides programs and services to needy and disadvantaged individuals and families through TANF, food stamps, employment/training programs, literacy programs, child care programs, child abuse and neglect services, foster care and adoption services, child support and medical support enforcement services, and providing care and treatment for children properly committed to the agency's custody. With offices in all 82 counties, this agency is integral in targeting and enrolling Medicaid and CHIP eligible children.

Department of Rehabilitation Services

This agency provides rehabilitation services to eligible disabled adults and children who are on Medicaid or who are uninsured. In addition, it currently processes and renders decisions on applications for Social Security Disability and Supplemental Security Income Disability and for the State's Medicaid blind and disabled coverage groups. This agency will be integral in identifying and enrolling children eligible for Medicaid and CHIP.

Department of Mental Health (DMH)

This agency provides all services in the state for the mentally ill, emotionally disturbed, alcoholic, drug dependant and mentally retarded persons. These services are provided through a system of Community Mental Health Centers in eight regions of the state, several ICF-MRs, and a system of acute and residential programs. These programs serve the Medicaid population, as well as the uninsured, particularly children. This agency will be integral in identifying and submitting application forms to the state agency with responsibility for determining eligibility for Medicaid and CHIP.

Department of Education (DOE)

The Department of Education has attached a form to its application for the School Lunch Program for families to indicate an interest in the CHIP. Interested families are provided applications to be brought to the Medicaid region office. DOE has been very cooperative in distributing CHIP materials (see page 4) and is eager to participate in CHIP outreach. Various initiatives in partnership with the Department of Education are used to identify, enroll and retain eligible children in Medicaid and CHIP such as screening of potential eligibles through the Free and Reduced Lunch Program or the $20 Incentive Program which ended January, 2005.

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

Effective Date: January 2005 Approval Date: June 2006 7 Mississippi Division of Medicaid (DOM)

This agency provides a statewide system of medical assistance, health care, remedial and institutional services under Titles XXI, XIX and XVIII of the Social Security Act. In partnership with the Department of Human Services, Department of Health, Department of Education, and the Department of Mental Health, the Division identifies and enrolls Medicaid eligible children. This partnership has been maintained and strengthened to identify and enroll CHIP eligible children. The State Department of Health and the Department of Mental Health serve as providers of services to Medicaid/CHIP eligible children and to uninsured children. The Division of Medicaid works with these agencies and a statewide coalition of other partners to identify, enroll and retain eligible children for MS Health Benefits Program (Medicaid and CHIP). In addition, the Division of Medicaid has expanded its school-based providers of EPSDT screening and treatment services. Through this avenue, the Medicaid agency will be able to utilize the schools to identify Medicaid eligible and CHIP eligible children. With out-stationed workers in federally qualified health centers (FQHCs), disproportionate share hospitals (DSH) hospitals and Health Department Clinics, the Medicaid agency will utilize these service providers to identify Medicaid and CHIP eligible children. The Medicaid agency will increase its reliance on primary care providers (PCP) through its fee-for-services providers to disseminate information about eligibility for both Medicaid and CHIP for children through its Medical Advisory Committee. The Medicaid agency established the State CHIP Steering Committee that is composed of representation from the Department of Finance and Administration (DFA), Department of Health, Department of Human Services (DHS), and the Department of Mental Health in order to be comprehensive in its approach in the provision of quality health services to all children. This committee meets quarterly, reviews program operations and gives recommendations.

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:

There is currently no public-private health initiative for children in Mississippi. The Blue Cross/Blue Shield Caring Program for Children was the only health program that resembled a public-private partnership. This program has been discontinued. According to Blue Cross/Blue Shield, this program was closed due to lack of private contributions for matching purposes. The last child was removed from the program in December 1997, but the program had not accepted any new enrollees for over a year prior to that.

Because of lack of any private insurance initiatives for children and families unable to afford any other kind of health care coverage, the 1998 Mississippi Legislature did establish the Mississippi Children’s Health Insurance Program

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

Effective Date: January 2005 Approval Date: June 2006 8 Commission, which explored the feasibility of a public-private partnership for children’s health care for targeted low-income children who do not qualify for Medicaid. DOM has received a HRSA State Planning Grant to identify potential health policy options for the under and uninsured through the establishment of public-private partnerships. The final report from that grant will be available by August 31, 2006.

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

As discussed previously, there are no other public or private programs designed to provide creditable coverage for low-income children. DOM does have on-going communication with private health insurance groups, present at their professional meetings, provides program information and updates and has an exchange of referrals.

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

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

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

Organization and Management

Coverage under the separate insurance program, as described above, is administered by the State and School Employees Health Insurance Management Board (hereinafter referred to as the Health Insurance Management Board), through an agreement with the Division of Medicaid. This Board is established by 25-15- 303 of the Mississippi Code (refer to Attachment E). The Board has the sole authority to promulgate rules and regulations governing the operations of the insurance plans under its purview and is vested with all legal authority necessary and proper to perform this function including, but not limited to the following for the State and School Employees’ Health Insurance Plan:

(a) Defining the scope and coverage provided by the insurance plans; (b) Seeking proposals for services or insurance through competitive processes where required by law and selecting service providers or insurers under procedures provided for by law; and

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

Effective Date: January 2005 Approval Date: June 2006 9 (c) Developing and adopting strategic plans and budgets for the insurance plan.

The Department of Finance and Administration (DFA) is authorized by this same law to provide staff assistance to the Board and to employ a State Insurance Administrator, who is responsible for the day-to-day management and administration of the insurance plans. The State Insurance Administrator oversees the Office of Insurance which also has responsibility for administering the State Agencies’ Workers’ Compensation Trust and the State and School Employees’ Life and Health Insurance Plan.

Eligibility and Outreach

Eligibility for CHIP is determined in the same manner and by the same agency as eligibility for Medicaid, the Division of Medicaid. For applications and re- determinations, a face-to-face interview is required. The State has designed a “short form” that closely resembles the federal model, which is available at community health centers, health department clinics, and other providers of primary care and on the internet. This application entitled MS Health Benefits Application with informational materials and updates is made available on an on-going basis, to these providers, to Head Start Programs, Tribal Nations, community action agencies, hospitals, primary care providers, pediatricians, family practitioners and schools throughout the state. On-going trainings are provided to the public. Special educational and outreach materials will continue to be developed and distributed by the State for CHIP. Applications may be taken at any of the 30 Medicaid regional offices or the established out stationed sites. Over 250 out stationed sites have been established across the state at hospitals, nursing facilities, health departments, medical clinics and federally qualified health centers.

In addition, DOM has established a Memorandum of Understanding with the Department of Education to assist with the identification and retention of eligible children, education of parents and distribution of applications and information. All families identified through this mechanism will be provided with an application or referred to the local regional Medicaid office.

The appeals process for eligibility denials for CHIP is the same process currently in place for denial of Medicaid eligibility. The process is set forth in state statute at Miss. Code Ann. Section 43-13-116.

Management of Coverage

The Health Insurance Management Board contracted with Blue Cross/Blue Shield of MS (BCBSMS) through a competitive bid process for health insurance coverage for children eligible for CHIP. The Board defines the minimum level of benefits to be provided by the contractor (see Section 6.2) BCBSMS provides enrollment, financial accounting services, and insurance coverage for the eligible population on a statewide basis. Such services include, but are not limited to, the following:

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

Effective Date: January 2005 Approval Date: June 2006 10

(a) Collecting enrollment data on eligible participants; (b) Responding to inquiries from potentially eligible families; (c) Providing a description of coverage and ID cards to enrolled participants; (d) Adjudicating claims; (e) Implementing an internal appeals process; (f) Processing payment to providers: (g) Responding to inquiries and complaints from members and providers; (h) Implementing appropriate utilization management; (i) Ensuring adequate access to providers; (j) Producing required and requested reports; (k) Submitting encounter data to the State’s Data Management Vendor; (l) Maintaining proper financial controls and reporting.; and (m) Conducting required data matches.

Coverage is made available to eligible children on a “guaranteed issue” basis. There are no exclusions for pre-existing conditions, and coverage is granted on a “guaranteed renewable” basis.

Employer-Sponsored Insurance Subsidy Feature

(Implementation of this feature is on hold for an indefinite time.)

For eligible children in families with access to employer-sponsored health insurance, the Plan will pay the insurance premium for coverage under the employer’s plan if the plan meets the following criteria:

(a) The employer’s plan meets benchmark coverage; the employer is willing to participate in the Children’s Health Insurance Program; (b) The employer contributes at least 50 percent of the premium for family coverage (employee + children); (c) The family has not enrolled the child(ren) in group coverage through the employer any time within the previous six months; (d) The cost to CHIP for purchasing coverage from the employer is no greater than the payment the program would make if the child(ren) were enrolled in the State’s Plan (excluding payments for services excluded as pre-existing under the employer’s plan); and (e) The family applies for the full premium contribution available from the employer.

The State has developed a checklist of benefits included in the benchmark coverage (refer to Attachment H). The State’s actuary will use this checklist to evaluate the benefits allowed under the employer’s plan based on the Summary Plan Description of the employer’s plan. If an employer-sponsored plan has a benefit design that makes it difficult to evaluate with the checklist, the State’s actuary will be asked to evaluate whether the employer-sponsored plan is equivalent to benchmark

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

Effective Date: January 2005 Approval Date: June 2006 11 coverage.

The following is a summary of the procedures that will be followed to determine if an employer-sponsored plan is eligible for premium subsidy:

(a) The actuary will compare the employer’s Summary Plan Description to the benchmark plan’s benefits on a benefit by benefit basis (see attached checklist). (b) If the employer’s plan of benefits match the benchmark plan’s benefits on a benefit by benefit basis (without regard to cost sharing), the employer’s plan will be considered to have passed this criterion and will be evaluated for cost. (c) If the employer’s plan of benefits does not match on a benefit by benefit basis, the plan may be rejected by the actuary as not equivalent to the benchmark plan or may undergo a full actuarial analysis by the actuary to compare the overall actuarial value of the employer’s plan to the actuarial value of the benchmark plan (without regard to cost sharing). This decision will be made by the actuary based upon the degree of difference in the particular benefit and whether or not there is another benefit where the employer’s plan exceeds the benchmark plan. If a benefit in the employer’s plan does not meet the level of the benchmark plan, but the difference is minor, and there is another benefit where the employer’s plan exceeds the benchmark plan, the actuary may perform the full actuarial analysis if in his opinion there is a reasonable potential that the full actuarial value of the employer’s plan is equivalent to or greater than the benchmark plan. In order to be approved, the employer’s plan must have an overall actuarial value equivalent to or greater than 100% of the benchmark’s plan actuarial value and the actuarial value in the following categories of benefits must be equal to or greater than 75% of the actuarial value of the coverage in the respective category in the benchmark plan: prescription drugs, mental health services, vision services, and hearing services.

(d) The State will submit copies of the benefit comparisons and actuarial analyses to CMS upon request. Children who qualify for payment of premiums under an employer-sponsored plan will receive ”secondary” or ”wrap-around” supplemental coverage under Mississippi’s CHIP plan to cover deductibles, co-insurance, co-payments, and pre-existing conditions. Providers will be asked to file claims for these amounts after the primary carrier has allowed benefits and issued an explanation of benefits. In order to ensure that families are not required to pay more than the specified co- payments, if any, under CHIP, the State’s communications to providers upon the implementation of CHIP will include the following information on cost sharing:

(a) There are no cost sharing requirements for children enrolled in CHIP except for the minimal co-payments for families over 150% of FPL; (b) Any charges for deductibles, co-insurance, or co-payments under

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

Effective Date: January 2005 Approval Date: June 2006 12 employer-sponsored plans are to be filed with the State’s CHIP insurer; (c) The federal law governing CHIP prohibits cost sharing with respect to benefits for well child care, including immunizations, and families may not be required to pay for these services at the point of service; and (d) There is no cost sharing for American Indian/Alaska Native children.

In addition, the State’s communications to providers upon the implementation of this premium-assistance feature will include claim filing procedures for both primary and secondary claims.

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

The contractor selected by the Health Insurance Management Board to provide insurance coverage for CHIP must have acceptable policies and procedures for utilization and disease management. These include at a minimum pre-certification for inpatient hospital stays and certain surgical and diagnostic procedures, as well as case management services for high cost or long-term conditions and a toll-free number staffed by nurses appropriately trained in disease management and triage. The health plan must also ensure that there are proper appeal procedures in place to preclude denial of care that is appropriate and medically necessary.

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

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5. 4.1. The following standards may be used to determine eligibility of targeted low-income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1.

Geographic area served the Plan: Statewide. 4.1.2.

Age: Birth through 18 years of age 4.1.3.

Income: 200% FPL. 4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): 4.1.5.

Residency (so long as residency requirement is not based on length of time in state): Currently residing in the State with intent to stay. 4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7.

Access to or coverage under other health coverage: Children who are eligible for Medicaid or who have creditable health coverage under

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

Effective Date: January 2005 Approval Date: June 2006 13 another plan at the time of application will not eligible for CHIP. 4.1.8.

Duration of eligibility: 12 months from the date of initial determination or until the child reaches age 19 years or becomes eligible for Medicaid whichever occurs first. A face to face interview is required for application and re-determination. 4.1.9.

Other standards (identify and describe): The applicant child over age 1 year must provide a social security number in accordance with provision (42.CFR457.340(b))

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

4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.

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

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

Eligibility for CHIP is determined in the same manner and by the same agency and workers as eligibility for Medicaid. Upon application and re-determination, a face-to- face interview is required. The State has a “short form” that closely resembles the federal model. These applications are available at community health centers, Head Start, health department clinics, and other providers of care as well all the local DHS offices, and on the DOM website.

The State provides twelve months of continuous enrollment in CHIP, except in instances where children reach the age of 19 years or become eligible for Medicaid, leave the State, acquire other insurance, become deceased, or at parent’s request. CHIP cases may also close if the State discovers and validates the enrollee had other insurance at the time of application or re-determination.

Due to the transition of eligibility from the Department of Human Services to the Division of Medicaid that occurred January 1, 2005, Medicaid specialists are entering all application information during the re-determination and application processes. An appointment for a face-to-face interview is mailed to CHIP enrollees during the month prior to the annual renewal month. Provision of verifications of income, dates of birth and social security numbers for members being re-determined is required. Once the information is received, the case is handled much like the initial application. The recipients are first screened for Medicaid. If ineligibility based on income and age is established, then the redetermination is screened for CHIP.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if

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

Effective Date: January 2005 Approval Date: June 2006 14 any). (Section 2106(b)(7)) (42CFR 457.305(b))

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

4.4. Describe the procedures that assure that:

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

The State uses a single application entitled MS Health Benefits Program (MHB) to apply for both Medicaid and CHIP. A completed MHB application is processed at the local regional Medicaid office by the Medicaid specialist. During the application process, the applicant is required to appear for an in- person interview, provide the household’s income verification and social security numbers for all applying. The first step at application is to determine the household’s income level and the age of the children involved. This information is first used to determine if any household member is Medicaid eligible in any of the state’s Medicaid programs. If ineligibility for Medicaid is established, the applicants are screened for CHIP.

The MHB application asks the applicants to provide information regarding any coverage under group health plan or health insurance coverage that anyone applying has had in the last six months. Once the application has been processed and approved, the private insurer notes issues as they arise on claims submitted that indicate other health insurance coverage or reports from parents/providers of other coverage. These reports are then followed up on at the state level in the CHIP Office and appropriate action is taken based on the resulting discovery.

Due to the transition of eligibility determination from the Department of Human Services to the Division of Medicaid that occurred January 1, 2005, Medicaid specialists are entering all application information during the re- determination and application processes. An appointment for a face-to-face interview is mailed to CHIP enrollee during the month prior to the annual renewal month. Provision of verifications of income, dates of birth and social security numbers for members being re-determined is required. Once the information is received, the case is handled much like the initial application. The recipients are first screened for Medicaid. If ineligibility based on income and age is established, then the re-determination is screened for CHIP.

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

Effective Date: January 2005 Approval Date: June 2006 15 As previously mentioned, if the private insurer for CHIP discovers a claim submitted listing any other insurance coverage the insurer provides this information to the state CHIP Office for further investigation. Pending the findings, the CHIP case may or may not be closed.

In Mississippi, the children of public agency employees with access to the State employee insurance plan who meet all eligibility requirements of CHIP can be covered under CHIP. The employees must pay the full cost of insurance coverage for dependent children without any subsidy from the State in accordance to policy guidance under Section 2110(b)(2)(B) of Title XXI.

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

Eligibility for CHIP will be determined by Medicaid specialists primarily located at local regional Medicaid offices as well as at out stationed sites, according to the same methodology currently used to determine eligibility for Medicaid. Only if applicants are determined ineligible for Medicaid, will they be considered for CHIP.

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

As fore mentioned, the State uses a single application entitled MS Health Benefits Program (MHB) to apply for Medicaid and CHIP. A completed MHB application will be processed at the regional Medicaid office by Medicaid specialist. It will be screened for eligibility for Medicaid first. If that screening results in ineligibility, the applicant is screened for eligibility for CHIP.

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

The applicant’s current insurance status is self-reported during the application and re-determination processes. As previously mentioned, if the private insurer for CHIP discovers a claim submitted listing any other insurance coverage for a recipient, the insurer provides this information to the state CHIP Office for further investigation. Pending the findings, the CHIP case may or may not be closed.

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

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

Effective Date: January 2005 Approval Date: June 2006 16 The state’s plan amendment to eliminate the 6-month waiting period was approved October 2000. As a condition of that approval, the State monitors on a monthly basis the number of children approved with prior creditable health insurance in the last six months as declared on the MBH application. When the number of children enrolled with prior coverage is 15% of the total CHIP children approved as of 10/2000, the State will seek to implement a new waiting period. To date, the percentage of children approved with prior coverage has remained below 4% of the total CHIP enrollment since 10/2000.

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

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

4.4.4.4. If the state provides coverage under a premium assistance program, describes: (On hold)

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

The minimum employer contribution. Not specified

The cost-effectiveness determination. The cost of covering a child through the employer plan must not exceed cost under the State program.

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

Leadership of the Mississippi Band of Choctaw Indians has been contacted directly, and a targeted strategy of outreach and determination of eligibility has been developed. As needed, training on the completion of the MHB application provided to identify staff of the Choctaw community. Out stationed Medicaid specialists are routinely scheduled on site to take MHB applications. (Refer to

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

Effective Date: January 2005 Approval Date: June 2006 17 Section 8.2 regarding the waiver of cost sharing requirements for American Indian/Alaskan Native children.)

Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

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

Medicaid and CHIP applications and information are distributed statewide through health care providers and a statewide coalition of collaborative partners. Families are informed of the availability of coverage under Titles XIX and XXI. Outreach activities consist of efforts to identify and enroll children who are eligible for both Medicaid and CHIP. As previously discussed, Medicaid is the only public health insurance program for children in the state, and there is currently no private health coverage for children who cannot afford to pay for it. Thus, Medicaid and CHIP enrollment represent the only viable public alternatives for the State's children to have creditable insurance coverage in this targeted population. The State recognizes the importance of outreach to families of children likely to be eligible for assistance and to encourage them to enroll and retain their children, the State has done the following:

(a) Reduced barriers to participation by using the same “short form” currently used to determine eligibility for Medicaid and CHIP; by streamlining income verification processes; dispensing with resource and asset tests for children, and by wide dissemination of application and information.; (b) Engaged in provider education efforts because providers are a vital link to this population; (c) Initiated cooperative efforts with the State Department of Health, the Department of Human Services, Department of Mental Health, Department of Education, the Department of Rehabilitation Services and Head Start regarding public awareness of these two programs; (d) Developed statewide coalitions to assist with the dissemination of materials and conducting a variety of outreach strategies such as health fairs and forums, development of informational fliers, posters, and other promotional items; (e) Engaged the print media as a means to educate providers; (f) Coordinated a number of community based initiatives to educate families with potentially eligible children; (g) Partnered with entities and programs through local and state inter-agency councils, school-based health programs, including Head start, and other community organizations whose missions include services to families and children; (h) Out stationed Medicaid specialists at FQHCs, Disproportionate Share Hospitals,

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

Effective Date: January 2005 Approval Date: June 2006 18 County Health Departments, Indian reservations, and through school-based EPSDT providers; and (i) Coordinated with the Department of Education, mechanisms to identify children in the targeted population for outreach activities and assessment for eligibility as well as provide another avenue for dissemination of information about CHIP.

Beyond administering outreach, the State will ensure that staff at the appropriate state agencies will be well trained to respond to inquiries from the public and provide progress reports to advocacy groups, the Legislature, and other interested parties.

Special Populations

The State works continuously with the Native American and Asian populations with the Medicaid and CHIP programs. The State has out stationed Medicaid specialists at Native Americans’ Health Facilities across the state in order to identify and enroll the children in either CHIP or Medicaid. On-going communication, technical assistance, and program information are provided to the coastal Catholic Charities Refugee Center that provides services to the largest Asian population in the State.

Teens will be reached through the Division of Medicaid’s outreach partners such as Jackson Hinds Community Health Center, Children Defense Fund who go into schools to conduct outreach both for eligibility and for access to EPSDT services. The State will also rely on the State Health Department clinics to help identify and enroll teens through family planning and other health outreach programs. The State has also identified public events, school, church, and community teen activities that reach teens.

The State works closely with the Mississippi School for the Deaf and the Mississippi School for the Blind to identify and enroll visually and hearing impaired children and also rely on their staff as resources for developing print and visual material for hearing impaired and audio material for vision impaired children and their families to learn about the CHIP program. The State also has sign language interpreters available to help with outreach and enrollment for hearing impaired children and limited English speaking population.

The State has targeted two areas of limited English proficiency: Spanish speaking families in the Southern part of the state and Vietnamese speaking families throughout the state. The State has subscribed to a language line service to help with on-site screening and enrollment processes. The State has printed materials in these two languages.

The State has begun to work closely with a children’s advocacy group, Children’s Health Matters, a coalition of advocates working through Catholic Charities, who is helping the Division of Medicaid define and find solutions to various barriers to enrollment in health programs for children, including Medicaid and CHIP. This group has committed their resources to address as many of these barriers along with the

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

Effective Date: January 2005 Approval Date: June 2006 19 state as is possible. This partnership has been formalized through a funded contractual agreement.

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

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

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

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.2. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.3.

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

6.1.3.

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

6.1.4.

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

6.1.5.

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

6.1.6. Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) 6.1.4.1. Coverage the same as Medicaid State plan 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3.

Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage

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

Effective Date: January 2005 Approval Date: June 2006 20 Coverage includes that of the State and School Employees’ Health Insurance Plan’s High Option Coverage for Children plus dental and vision coverage. 6.1.4.5.

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

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

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

6.2.1.

Inpatient services (Section 2110(a)(1)) Must be pre-certified as medically necessary and includes the following: (1) Hospital room and board (including dietary and general nursing services) (2) Use of operating or treatment rooms. (3) Anesthetics and their administration. (4) Intravenous injections and solutions. (5) Physical therapy. (6) Radiation therapy. (7) Oxygen and its administration. (8) Diagnostic services, such as x-rays, clinical laboratory examination, electrocardiograms, and electroencephalograms. (9) Drugs and medicines, sera, biological and pharmaceutical preparations used during hospitalization which are listed in the hospital's formulary at the time of hospitalization, including charges for "take home" drugs. (10) Dressings and Supplies, sterile trays, casts, and orthopedic splints. (11) Blood transfusions, including the cost of whole blood, blood plasma and expanders, processing charges, administrative charges, equipment and Supplies. (12) Psychological testing when ordered by the physician and performed by a full-time employee of the hospital subject to limitations. (13) Intensive, Coronary, and Burn Care Unit services. (14) Occupational therapy. (15) Speech therapy.

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

Effective Date: January 2005 Approval Date: June 2006 21 6.2.2.

Outpatient services (Section 2110(a)(2)) See Physician Services and Surgical Services.

6.2.3.

Medical services (Section 2110(a)(3)) Includes the following: (1) In-hospital medical care. (2) Medical care in the physician's office, enrollee’s home, or elsewhere. (3) Surgery. (4) Dental care, treatment, dental surgery, and dental appliances made necessary by accidental bodily injury to sound and natural teeth (which are free from effects of impairment or disease) effected solely through external means occurring while the enrolled child is covered under the Program. Injury to teeth as a result of chewing or biting is not considered an Accidental Injury. Covered medical expense must be incurred as a direct result of an accidental injury to natural teeth and medical treatment must begin within ten days of the accidental injury. (5) Administration of anesthesia. (6) Diagnostic services, such as clinical laboratory examinations, x-ray examinations, electrocardiograms, electroencephalograms, and basal metabolism tests. (7) Radiation therapy. (8) Consultations. (9) Psychiatric and psychological service for nervous and mental conditions. (10) Physicians assisting in surgery, where appropriate. (11) Emergency care or surgical services rendered in a practitioner’s office including but not limited to surgical and medical supplies, dressings, casts, anesthetic, tetanus, serum and x-rays. (12) Well child assessments, including vision screening, laboratory tests and hearing screening, according to recommendations of the U.S. Preventive Service Task Force. Vision and hearing screening are to be included as part of the periodic well child assessments. (13) Routine immunizations (according to ACIP guidelines)- Vaccine is purchased and distributed through the State Department of Health. The health plan will reimburse providers for the administration of the vaccine.

6.2.4.

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

Certain surgeries must be pre-certified as medically necessary.

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

Effective Date: January 2005 Approval Date: June 2006 22

Benefits are provided for the following covered medical expenses furnished to the enrollee by an Ambulatory Surgical Facility: (1) Services consisting of routine pre-operative laboratory procedures directly related to the surgical procedure. (2) Pre-operative preparation. (3) Use of facility (operating rooms, recovery rooms, and all surgical equipment). (4) Anesthesia, drugs and surgical Supplies.

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

Covered as medical services (refer to 6.2.3.).

6.2.6.

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

The following drugs and medical supplies are covered: (1) Legend drugs (federal law requires these drugs be dispensed by prescription only) (2) Compounded medication of which at least one ingredient is a legend drug (3) Disposable blood/urine glucose/acetone testing agents (e.g., Chemstrips, Acetest tablets, Clinitest tablets, Diastix Strips and Tes-Tape) (4) Disposable insulin needles/syringes (5) Growth hormones (6) Insulin (7) Lancets (8) Legend contraceptives (9) Retin-A (10) Fluoride supplements (e.g., Gel-Kam, Luride, Prevident, sodium fluoride tablets) (11) Vitamin and mineral supplements, when prescribed as replacement therapy

The following are excluded: (1) Anabolic steroids (e.g., Winstrol, Durabolin) (2) Anorectics (any drug used for the purpose of weight loss) with the exception of Dexadrine and Adderall for Attention Deficit Disorder (3) Anti-wrinkle agents (e.g., Renova) (4) Charges for the administration or injection of any drug (5) Dietary supplements (6) Infertility medications (e.g., Clomid, Metrodin, Pergonal, Profasi)

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

Effective Date: January 2005 Approval Date: June 2006 23 (7) Minerals (e.g., Phoslo, Potaba) (8) Minoxidil (Rogaine) for the treatment of alopecia (9) Non-legend drugs other than those listed as covered (10) Pigmenting/depigmenting agents (11) Drugs used for cosmetic purposes (12) Smoking deterrent medications containing nicotine or any other smoking cessation aids, all dosage forms (e.g., Nicorrette, Nicoderm, etc) (13) Therapeutic devices or appliances, including needles, syringes, support garments and other non-medicinal substances, regardless of intended use, except those listed as covered, such as insulin needles and syringes (14) Any medication not proven effective in general medical practice (15) Investigative drugs and drugs used other than for the FDA approved diagnosis (16) Drugs that do not require a written prescription (17) Prescription Drugs if an equivalent product is available over the counter (18) Refills in excess of the number specified by the practitioner or any refills dispensed more than one year after the date of practitioner’s original prescription

6.2.7.

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

6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) Certain diagnostic tests must be pre-certified.

6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9)) Infertility services are excluded.

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))

(1) Benefits for Covered Medical Expenses are paid for medically necessary inpatient psychiatric treatment of an enrollee for a period of up to thirty (30) days annually. (2) Benefits for covered medical expenses are provided for Partial Hospitalization for a period of up to sixty (60) days annually. (3) Certification of medical necessity by the Insurer’s Utilization Review Program is required for admissions to a hospital.

Benefits for mental/nervous conditions do not include services where the primary diagnosis is substance abuse.

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

Effective Date: January 2005 Approval Date: June 2006 24

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)

Benefits for Covered Medical Expenses for treatment of nervous and mental conditions on an outpatient basis are limited to 52 visits annually. Benefits for mental/nervous conditions do not include services where the primary diagnosis is substance abuse

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))

Rental of Durable Medical Equipment is covered for temporary therapeutic use; provided, however, at the Insurer’s discretion, the purchase price of such equipment may be allowed. To be Durable Medical Equipment, an item must be (1) made to withstand repeated use; (2) primarily used to serve a medical purpose; (3) generally not useful to a person in the absence of illness, injury or disease; and (4) appropriate for use in the enrollee’s home.

Prosthetic or Orthotic Devices necessary for the alleviation or correction of conditions arising from accidental injury, illness, or congenital abnormalities are covered services. Benefits are available for the initial placement, fitting, and purchase of Prosthetic or Orthotic devices that require a prescription by a physician and for the repair or replacement when medically necessary. Shoes are not covered except for the following: (1) a surgical boot which is part of an upright brace, (2) one pair of mismatched shoes annually in instances where a foot size disparity is greater than two sizes, and (3) a custom fabricated shoe in the case of a significant foot deformity.

Eyeglasses (limited to one per year) and hearing aids (limited to one every three years) are covered services.

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

Supplies provided under the Plan which are medically necessary disposable items, primarily serving a medical purpose, having therapeutic or diagnostic characteristics essential in enabling an enrollee to effectively carry out a practitioner’s prescribed treatment for illness, injury, or disease, and are appropriate for use in the enrollee’s home.

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

Effective Date: January 2005 Approval Date: June 2006 25 6.2.14.  Home and community-based health care services (See Instructions) (Section 2110(a)(14))

Services and supplies required for the administration of Home Infusion Therapy regimen must be (1) medically necessary for the treatment of the disease; (2) ordered by a practitioner; (3) as determined by the Insurer’s Utilization Review Program capable of safe administration in the home; (4) provided by a licensed Home Infusion Therapy provider coordinated and pre-certified by the Insurer’s Utilization Review Program ; (5) ordinarily in lieu of inpatient hospital therapy; and (6) more cost effective than inpatient therapy.

Benefits for home health nursing services must be approved by the Insurer’s Utilization Review Program in lieu of hospitalization. Benefits for nursing services are limited to $10,000 annually.

6.2.15. 

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

Benefits include nursing services of an actively practicing Registered Nurse (RN) or Licensed Practical Nurse (LPN) when ordered and supervised by a practitioner and when the services rendered require the technical skills of an RN or LPN.

Benefits are provided for covered medical expense when performed by a nurse practitioner practicing within the scope of his or her license at the time and place service is rendered.

Benefits for private duty nursing services are provided for an illness or injury that the Insurer’s Utilization Review Program determines to be of such a nature and complexity that the skilled nursing services could not be provided by the hospital's nursing staff. A shift of eight (8) continuous hours or more is required for private duty nursing services. Benefits are also provided for nursing services in the home for illness or injury that the Insurer’s Utilization Review Program determines to require the skills of an RN or LPN. Benefits for nursing services provided in an enrollee’s home must be approved by the Insurer’s Utilization Review Program in lieu of hospitalization. Benefits for nursing services are limited to $10,000 annually. (This limit does not apply to nurse practitioner services.) No nursing benefits are provided for: (1) Services of a nurse who ordinarily lives in the child’s home or is a member of the child’s family; (2) Services of an aide, orderly or sitter; or (3) Nursing services provided in a Personal Care Facility.

Benefits are provided for confinement in a skilled nursing facility for up

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

Effective Date: January 2005 Approval Date: June 2006 26 to 60 days per benefit period, subject to utilization management requirements.

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)

Benefits are allowed for elective abortion only when documented to be medically necessary in order to preserve the life or physical health of the mother.

6.2.17.

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

Covered dental services are limited to $1500 each calendar year

(1) Benefits will be provided for preventive and diagnostic dental care as recommended by the American Academy of Pediatric Dentistry (AAPD). a. Bitewing X-rays - as needed, but no more frequently than once every six months; b. Complete Mouth X-ray and Panoramic X-ray - as needed, but no more frequently than once every twenty-four (24) months; c. Prophylaxis - one every six months; must be separated by six full months; d. Fluoride Treatment - limited to one each six month period; e. Space Maintainers - limited to permanent teeth through age 15 years; and f. Sealants - covered up to age 14 years, every thirty-six months.

(2) Benefits are provided for restorative, endodontic, periodontic, and surgical dental services, as indicated below, and are limited to $1500 each calendar year. a. Amalgam, Silicate, Sedative and Composite Resin Fillings including the replacement of an existing restoration; b. Stainless steel crowns to posterior and anterior teeth; c. Porcelain crowns to anterior teeth only; d. Simple extraction; e. Extraction of an impacted tooth; f . Pulpotomy, pulpectomy, and root canal; and g. Gingivectomy, gingivoplasty and gingival curettage.

Other Dental Services (The Calendar Year Maximum does not apply to these services.)

(1) Benefits are provided for dental care, treatment, dental surgery, and dental appliances made necessary by accidental bodily injury to sound and natural teeth (which are free from effects of impairment or

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

Effective Date: January 2005 Approval Date: June 2006 27 disease) effected solely through external means occurring while the enrolled child is covered under the Program. Injury to teeth as a result of chewing or biting is not considered an accidental injury. (2) Benefits are provided for anesthesia and for associated facility charges when the mental or physical condition of the enrolled child requires dental treatment to be rendered under physician-supervised general anesthesia in a hospital setting, surgical center or dental office. These services must be pre-certified. (3) No benefits will be provided for orthodontics, dentures, occlusion reconstruction, or for inlays unless such services are provided pursuant to an accidental injury as described above or when such services are recommended by a physician or dentist for the treatment of severe craniofacial anomalies or full cusp Class III malocclusions. Diagnosis and surgical treatment for temporomandibular joint (TMJ) disorder or syndrome and craniomandibular disorder, whether such treatment is rendered by a practitioner or dentist, is subject to a lifetime maximum benefit of $5,000 per member. This lifetime maximum will apply regardless of whether the temporormandibular / craniomandibular joint disorder was caused by an accidental injury or was congenital in nature.

6.2.18.

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

Benefits for covered medical expenses are provided for the treatment of substance abuse, whether for alcohol abuse, drug abuse, or a combination of alcohol and drug abuse, as follows:

(1) Benefits for covered medical expenses are provided for medically necessary inpatient stabilization and residential substance abuse treatment. (2) Certification of medical necessity by the Insurer’s Utilization Review Program is required for admissions to a hospital or residential treatment center. (3) Benefits for inpatient and outpatient care shall not exceed $8,000 during a Benefit Period and shall not exceed a Lifetime Maximum of $16,000 except a $1,000 per benefit period will be provided for inpatient and outpatient alcohol abuse once the enrollee’s $16,000 lifetime maximum is exhausted. (4) Benefits for substance abuse do not include services for treatment of nervous and mental conditions.

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

(1) Benefits are provided for covered medical expenses for medically necessary Intensified Outpatient Programs in a

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

Effective Date: January 2005 Approval Date: June 2006 28 hospital, an approved licensed alcohol abuse or chemical dependency facility, or an approved drug abuse treatment facility. (2) Benefits are provided for covered medical expenses for substance abuse treatment while not confined as a hospital inpatient. (3) Benefits for inpatient and outpatient care shall not exceed $8,000 during a Benefit Period and shall not exceed a Lifetime Maximum of $16,000 except a $1,000 per benefit period will be provided for inpatient and outpatient alcohol abuse once the enrollee’s $16,000 lifetime maximum is exhausted. (4) Benefits for substance abuse do not include services for treatment of nervous and mental conditions.

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

Medical Case Management may be performed by the Utilization Review Program for those children who have a catastrophic or chronic condition. Through medical case management, the Utilization Review Program may elect to (but is not required to) extend covered benefits beyond the benefit limitations and/or cover alternative benefits for cost-effective health care services and supplies which are not otherwise covered. The decision to provide extended or alternative benefits is made on a case-by-case basis to covered children who meet the Utilization Review Program’s criteria then in effect. Any decision regarding the provision of extended or alternative benefits is made by the Utilization Review Program.

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))

Benefits are provided for physical therapy services specified in a plan of treatment prescribed by the enrollee’s practitioner and provided by a licensed physical therapist.

Benefits are provided for medically necessary occupational therapy services prescribed by the enrollee’s practitioner and specified in a treatment plan. Occupational therapy services must be provided by a licensed occupational therapist.

Benefits are provided for medically necessary speech therapy services prescribed by the enrollee’s practitioner and specified in a treatment plan. Speech therapy is not covered for maintenance speech, delayed language development, or articulation disorders.

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

Effective Date: January 2005 Approval Date: June 2006 29

Benefits are provided for an annual hearing examination, if indicated by the results of a hearing screening.

6.2.23.

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

Benefits are provided for inpatient and home hospice services, subject to utilization management requirements. Benefits for hospice services are limited to an overall lifetime maximum of $15,000.

6.2.24.

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

Benefits are provided for general anesthesia service when requested by the attending physician and performed by an anesthesiologist or a certified registered nurse anesthetist practicing within the scope of his or her license at the time and place service is rendered.

Transplant Benefits:

(1) Any human solid organ or bone marrow/stem cell transplant is covered, provided the following applies: (i) The enrollee or provider obtains prior approval from the Insurer’s Utilization Management Program; and (ii) The condition is life-threatening; and (iii) Such transplant for that condition is the subject of an ongoing phase III clinical trial; and (iv) Such transplant for that condition follows a written protocol that has been reviewed and approved by an institutional review board, federal agency or other such organization recognized by medical specialists who have appropriate expertise; and (v) The enrollee is a suitable candidate for the transplant under the medical protocols used by the Insurer’s Utilization Management Program. (2) In addition to regular benefits, benefits are provided for surgical, storage, and transportation expenses incurred and directly related to the donation of an organ or tissue used in a covered organ transplant procedure. (3) Benefits are provided for transportation costs of recipient and two other individuals to and from the site of the transplant surgery and reasonable and necessary expenses for meals and lodging of two individuals at the site of transplant surgery. Reasonable and necessary expenses for transportation, meals, and lodging of two other individuals are provided. Only those expenses which are

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

Effective Date: January 2005 Approval Date: June 2006 30 incurred at the time of the transplant surgery are eligible for reimbursement. Travel expenses incurred as a result of pre-operative and post-operative services are not eligible for reimbursement. Only actual travel expenses supported by receipts are reimbursed. In any event, the total benefits for transportation, meals, and lodging are limited to $10,000. (4) If a covered solid organ or tissue transplant is provided from a living donor to a human transplant recipient: (i) The following expenses are covered: ● A search for matching tissue, bone marrow or organ ● Donor's transportation ● Charges for removal, withdrawal and preservation ● Donor's hospitalization (ii) When only the recipient is a enrolled in the Program, the donor is entitled to donor coverage benefits. The donor benefits are limited to only those not available to the donor from any other source. This includes, but is not limited to, other insurance coverage or any government program. Benefits provided to the donor will be paid under the recipient’s contract. (iii) When both the recipient and the donor are enrolled in the Program, the donor is entitled to benefits under the donor’s contract. (iv) When only the donor is a Plan participant, the donor is not entitled to donor coverage benefits. No benefits are provided to the non-member transplant recipient. (v) If any organ or tissue is sold rather than donated to the enrollee, no benefits are payable for the purchase price of such organ or tissue;

Manipulative therapy is a covered medical expense but benefits shall not exceed $1,500 annually.

Benefits are provided for medically necessary services and supplies required for the treatment of injury or disease of the eye which fall within the legal scope of practice of a licensed optometrist. Benefits are provided for annual routine eye examinations, eyeglasses, and the fitting of eyeglasses.

Benefits are provided for diabetes self-management training and education, including medical nutrition therapy, for the treatment of diabetes, subject to a limitation of $250 per benefit period.

6.2.25.

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

6.2.26.

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

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

Effective Date: January 2005 Approval Date: June 2006 31

Professional ambulance services to the nearest hospital, which is equipped to handle the enrollee’s condition in connection with covered hospital inpatient, care; or when related to and within 72 hours after accidental bodily injury or medical emergency whether or not inpatient care is required.

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))

Limitations and Exclusions:

a. For convalescent, custodial, or domiciliary care or rest cures, including room and board, with or without routine nursing care, training in personal hygiene and other forms of self-care or supervisory care by a physician for an enrollee who is mentally or physically disabled as a result of retarded development or body infirmity, or who is not under specific medical, surgical or psychiatric treatment to reduce his disability to the extent necessary to enable him to live outside an institution providing care; neither shall benefits be provided if the enrollee was admitted to a hospital for his or her own convenience or the convenience of his or her physician, or that the care or treatment provided did not relate to the condition for which the enrolled child was hospitalized, or that the hospital stay was excessive for the nature of the injury or illness, it being the intent to provide benefits only for the services required in relation to the condition for which the enrolled child was hospitalized and then only during such time as such services are medically necessary. b. For cosmetic purposes, except for correction of defects incurred by the enrollee while covered under the Program through traumatic injuries or disease requiring surgery. c. For sex therapy or marriage or family counseling. d. For custodial care, including sitters and companions. e. For equipment that has a non-therapeutic use (such as humidifiers, air conditioners or filters, whirlpools, wigs, vacuum cleaners, fitness supplies, etc.). f. For procedures, which are Experimental/Investigative in nature. g. For palliative or cosmetic foot care including flat foot conditions, supportive devices for the foot, the treatment for subluxations of the foot, care of corns, bunions (except capsular or bone surgery), calluses, toenails, fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet. h. For services and supplies related to infertility, artificial insemination, intrauterine insemination and in vitro fertilization regardless of any claim to be medically necessary. i. For services which the Insurer’s Utilization Review Program determines are not

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

Effective Date: January 2005 Approval Date: June 2006 32 medically necessary for treatment of injury or illness. j. For services provided under any federal, state, or governmental plan or law including but not limited to Medicare except when so required by federal law. k. For nursing or personal care facility services i.e., extended care facility, nursing home, or personal care home, except as specifically described elsewhere. l. For treatment or care for obesity or weight control including diet treatment, gastric or intestinal bypass or stapling, or related procedures regardless of any claim of medical necessity or degree of obesity. m. For inpatient rehabilitative services consisting of the combined use of medical, social, educational or vocational services, or any such services designed to enable enrollees disabled by disease or injury to achieve functional ability, except for acute short-term care in a hospital or rehabilitation hospital as approved by the Insurer’s Utilization Review Program. n. For outpatient rehabilitative services consisting of pulmonary rehabilitation, or the combined use of medical, social, educational or vocational services, or any such services designed to enable enrollees disabled by disease or injury to achieve functional ability, except for physical, occupational, or speech therapy services specified in a plan of treatment prescribed by the enrollee’s physician and provided by a licensed therapist. o. For care rendered by a provider, (physician or other provider) who is related to the covered enrollee by blood or marriage or who regularly resides in the enrolled child’s household. p. For services rendered by a provider not practicing within the scope of his license at the time and place service is rendered. q. For treatment related to sex transformations regardless of claim of medical necessity or for sexual function, sexual dysfunction or inadequacies not related to organic disease. r. For reversal of sterilization regardless of claim of medical necessity. s. For elective abortion unless documented to be medically necessary in order to preserve the life or physical health of the mother. t. For charges for telephone consultations, failure to keep a scheduled visit, completion of a claim form, or to obtain medical records or information required to adjudicate a claim. u. For travel, whether or not recommended by a physician, except as provided for under Transplant Benefits. v. Because of diseases contracted or injuries sustained as a result of war, declared or undeclared, or any act of war. w. For treatment of any injury arising out of or in the course of employment or any sickness entitling the enrollee to benefits under any Workers' Compensation or Employer Liability Law. x. For any injury growing out of a wrongful act or omission of another party for which injury that party or some other party makes settlement or is legally responsible; provided, however, that if the enrollee is unable to recover from the responsible party, benefits shall be provided. y. For refractive surgery such as radial keratotomy and other procedures to alter the refractive properties of the cornea.

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Effective Date: January 2005 Approval Date: June 2006 33

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

6.3.1.

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

6.3.2.

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

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

6.4.1.

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

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

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

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

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

Effective Date: January 2005 Approval Date: June 2006 34 community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2.

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

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

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

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

Section 7. Quality and Appropriateness of Care

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

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

See response to Section 9.3.

In order to ensure that children receive appropriate and timely access to routine childhood immunizations, and in order to ensure that the State is able to properly monitor immunization rates for CHIP children, the Division of Medicaid purchases vaccine through the State Department of Health which distributes it to providers in a manner similar to that used for the Vaccine for Children Program. The vaccine is supplied to providers free of charge, and providers must agree to participate in the State’s Immunization Registry. The health plan providing health insurance coverage for CHIP children reimburses for the administration of the vaccine. In addition, all county health departments in the state provide childhood immunizations for a minimal administration fee, and the State Department of Health bills the CHIP health

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

Effective Date: January 2005 Approval Date: June 2006 35 plan for the administration fee for all immunizations provided to CHIP children so that there is no cost to the family.

Providers participating in the health plan’s network are prohibited from requiring any cost sharing for preventive services, including immunizations, rendered to children enrolled in CHIP.

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

The health plan submits encounter data to the Data Management Vendor (DMV) used by the Department of Finance and Administration for participants in the State and School Employees’ Health Insurance Plan. The vendor currently is The MEDSTAT Group. MEDSTAT compiles the data and provides reports, such as HEDIS-like reports, as well as allows the development of ad hoc reports using the MEDSTAT system. The enrollment file is matched annually with the State Immunization Registry to determine the immunization status of two-year olds enrolled in CHIP.

The health plan distributes a member booklet to all enrollees describing their coverage. The plan also annually conducts a consumer satisfaction survey.

7.1.4.

Quality improvement strategies

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

The health plan is required to meet certain access standards under the contract for the Children’s Health Insurance Program. These access standards include assuring that at least 85 percent of children have access to a primary care physician within 15 miles in urban/suburban areas and 25 miles in rural areas, and a hospital within 25 miles in urban/suburban areas and 45 miles in rural areas. The health plan conducts a GeoAccess analysis of providers in the network compared to the enrollment file to measure access levels. The health plan is required to conduct a member satisfaction survey at least annually. This survey includes questions related to access to health care services.

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

Through MEDSTAT, the State monitors the number and rate of well-child

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

Effective Date: January 2005 Approval Date: June 2006 36 visits by age group. By matching with the State Immunization registry, the State determines the immunization rate for two year olds.

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

The State requires the health plan to provide access to emergency services based on the State’s definition of a medical emergency, which is “the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care to result in: (1) permanently placing the patient’s health in jeopardy, (2) serious impairment of bodily functions; or (3) serious and permanent dysfunction of any bodily organ or part, or other serious medical consequences. Determination of a medical emergency shall be based on presenting symptoms rather than final diagnosis.

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

The health plan provides case management services for children with complex, often high cost, medical conditions. If care is not available in- network, approval is given to access care on an out-of-network basis.

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

The health plan reports on the rate of response to utilization management contacts.

The health plan’s decisions related to the prior authorization of health services are completed in accordance with the medical needs of the patient and federal regulations. These decisions are determined within the 14 days time frame for medical requests. For health services, the State uses health insurance law, not the Medicaid fair hearing process since CHIP is a health insurance plan.

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

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Effective Date: January 2005 Approval Date: June 2006 37

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

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

8.1.1. YES 8.1.2. NO, Skip to Question 8.8.

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

8.2.1. Premiums: None 8.2.2. Deductibles: None

8.2.3. Coinsurance or copayments: Requirement

≤150% FPL 151%-175% FPL

176% - 200% FPL

Per doctor visit None $5.00

$5.00

Per ER visit

None $15.00

$15.00

Out-of-Pocket

NA $800

$950 Maximum

8.2.4. Other: Co-payments as outlined in the following table.

No cost sharing is applied to preventive services, including immunizations, well child care, routine preventive and diagnostic dental services, routine dental fillings, routine eye examinations, eyeglasses, or hearing aids.

There is no cost sharing for American Indian/Alaska Native children.

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

All cost sharing requirements are described in the member booklet(s).

The Rules and Regulations governing the program are filed with the Secretary of State’s office. Information regarding cost sharing is included in this document. Interested parties may access this document from the Department of Finance and Administration’s website. Questions can also be addressed by calling the toll

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

Effective Date: January 2005 Approval Date: June 2006 38 free Customer Service number of the health plan.

Individual participants are notified of cost sharing responsibilities through their member booklets. The individual identification card also indicates cost sharing amounts and cumulative maximum. The health plan maintains the cost sharing accounting for the participant. When a participant has met his/her out of pocket maximum, the health plan sends a letter to the participant indicating that no further co-payments should be made for the remainder of the calendar year. The participant is instructed to present this letter when future health services are sought, or request the provider to contact the health plan regarding this issue.

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

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.

No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3

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

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

The Health Plan providing coverage tracks each family’s out-of-pocket expenses. If a family’s annual aggregate cost-sharing amount reaches the out-of-pocket amount noted in Section 8.2.4 (which is below 5 percent of the family’s annual income) the family will receive notification that no further cost sharing is required for the remainder of the year. This notification can be used by the family to document to health care providers that no co-payments are to be collected for services provided.

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

There is no cost sharing for American Indian/Alaska Native children. These children are classified separately so that there is no cost sharing applied regardless of income.

Through the application process, the applicant self-declares his/her race and ethnicity. DOM, the agency responsible for eligibility determination, notifies the

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

Effective Date: January 2005 Approval Date: June 2006 39 health plan of an American Indian/Alaska Native enrollee through a specific code in the enrollment data transfer process. DOM currently assigns out stationed Medicaid specialist to take applications at the Indian Reservation.

The health plan enrolls American Indian/Alaska Native children in a separate contract type, which has no cost sharing requirements, regardless of poverty category. The member booklet sent to these participants explains that there is no out of pocket expenses for covered services.

8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c)) Families are not disenrolled due to non-payment of copayments. (Member booklet explains that a provider may refuse service if unpaid)

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

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

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

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

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

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

8.8.1.

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

8.8.2.

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

8.8.3.

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

8.8.4.

Income and resource standards and methodologies for determining

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

Effective Date: January 2005 Approval Date: June 2006 40 Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5))

8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475)

8.8.6.

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

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

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

1. The infrastructure of the Mississippi Medicaid agency will be able to accommodate all critical facets of outreach and eligibility determination for the Title XXI program. 2. Previously uninsured children who will potentially be eligible for Mississippi’s Title XXI program will be identified through ongoing outreach activities involving other state agencies, social/healthcare providers, schools, Head Start, community/faith-based organizations, and advocates. 3. Low income children who were previously without health insurance coverage will have health insurance coverage through Mississippi's Title XXI program. 4. Children enrolled in CHIP will have adequate access to primary care, inpatient care, and pharmacy services. 5. Children enrolled in CHIP will receive appropriate preventive and primary care services. 6. Families of CHIP enrollees will be surveyed annually regarding their satisfaction with the services provided under the Program

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

Performance Goal for Objective 1:

The capacity within the Mississippi Division of Medicaid was appropriately expanded or modified to conduct outreach, enrollment and eligibility determination activities as needed to enroll uninsured eligible children. These areas include data systems modification, eligibility determinations, enrollment, participation information, health service utilization, billing, health status, provider information, personnel, (eligibility workers, administrative and support staff), staff training, and publications and

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

Effective Date: January 2005 Approval Date: June 2006 41 documents.

Performance Goals for Objective 2:

(1) The Medicaid agency has re-evaluated its existing outreach activities and developed materials for wide-spread dissemination throughout the state as needed; (2) The State will define ways to identify and enroll the State's ethnic minorities e.g., Native Americans, Asian Americans, Hispanics; (3) It is not anticipated that the State will need to increase the number of eligibility workers initially. As of January 1, 2005, DOM assumed the responsibility of eligibility determination for MHB. The State expanded the twenty-five regional offices to thirty and deployed over four hundred Medicaid specialists to the thirty regional Medicaid offices as well as over two hundred outstationed sites, and (4) Potentially eligible children for Medicaid and CHIP are identified through the school lunch program and Head Start.

Performance Goals for Objective 3:

By October 1, 2005, at least 65,000 CHIP enrollees will be maintained in the Program.

Performance Goal for Objective 4:

At least 85% of children enrolled in CHIP will have access to a primary care physician within 15 miles in urban/suburban areas and 25 miles in rural areas.

At least 85% of children enrolled in CHIP will have access to a hospital within 25 miles in urban/suburban areas and 45 miles in rural areas.

At least 85% of children enrolled in CHIP will have access to a pharmacy within 15 miles in urban/suburban areas and 25 miles in rural areas.

Performance Goal for Objective 5:

At least 85 % of two year olds enrolled in CHIP will have received all appropriate immunizations.

At least 85% of CHIP enrollees who were 2 to 6 years of age will have received at least one preventive or primary care visit during the year.

Performance Goals for Objective 6:

At least 90% of families responding to the member satisfaction survey will express satisfaction with customer service and provider access.

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Effective Date: January 2005 Approval Date: June 2006 42

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

Mississippi's Management Information Retrieval System (MMIRS) provides expanded on-line, age specific utilization data that will be used in monitoring the enrollment of the established performance goals for CHIP population. In CHIP, the health plan provides encounter data to the State’s Data Management Vendor (currently MEDSTAT) so that the vendor can produce required reports and provide the data to the Department of Finance and Administration for further analysis through the decision support system.

MEDSTAT is currently able to measure and track the following HEDIS performance measures for the targeted CHIP population:

(a) Well child visits in the 3rd, 4th, 5th, and 6th years of life; (b) Use of appropriate medications for children with asthma; (c) Children’s access to primary care practitioners; (d) Drug utilization; (e) Inpatient utilization – general hospital/acute care; (f) Mental health utilization; and (g) Annual dental visits.

Objective 1:

Eligibility and enrollment are evaluated on an ongoing basis. Reports from Envision, DOM’s patient information management system, on the number of applications approved, pending and denied are reviewed on a monthly basis and appropriate interventions implemented as indicated. The activities of each Medicaid specialist are monitored to determine maximum worker caseload.

Objective 2:

Through state, community, and advocacy networks, outreach activities are coordinated and evaluated. Recommendations from an internal survey and from the Outreach and Assessment and focus groups conducted by an outside consultant will be implemented as appropriate and further evaluated. Successful activities with targeted populations will be duplicated. The State will further define and refine its outreach strategies as more specific data is made available from a planned study of the uninsured children in Mississippi.

Objective 3:

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

Effective Date: January 2005 Approval Date: June 2006 43 Enrollment is measured by the Division of Medicaid, which provides eligibility determination services for both Medicaid and CHIP.

Objective 4:

Access is measured by the health plan using GeoAccess software applied to the CHIP enrollment file and network provider file.

Objective 5:

Immunization rates are measured by the State Department of Health by comparing the CHIP enrollment file against the State’s Immunization Registry.

Utilization of preventive and primary care services is measured through the State’s decision support system supported by the MEDSTAT Group. The health plan provides encounter data to MEDSTAT, and MEDSTAT loads the data into the decision support system which provides standard reports, as well as the ability to produce ad hoc reports.

Objective 6:

Satisfaction is measured by the health plan through an annual member satisfaction survey.

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

9.3.1.

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

The reduction in the percentage of uninsured children. 9.3.3.

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

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

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

9.3.6.

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

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1.

Immunizations 9.3.7.2.

Well child care 9.3.7.3.

Adolescent well visits 9.3.7.4.

Satisfaction with care

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

Effective Date: January 2005 Approval Date: June 2006 44 9.3.7.5.

Mental health 9.3.7.6.

Dental care 9.3.7.7.

Other, please list:

Access to primary care

9.3.8. Performance measures for special targeted populations.

9.4.

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

9.5.

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

Again, the Medicaid agency uses the same staff as well as the Department of Finance and Administration staff to evaluate and assess CHIP quality of care

There are reliable state-wide or comparable sub-group measures of morbidity of the Medicaid population to measure the effectiveness of the coverage of individuals enrolled in this proposed expansion.

In CHIP, the health plan submits encounter data to MEDSTAT. The decision support software supplied by MEDSTAT provides standard reports as well as enables ad hoc reporting.

9.6

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

9.7.

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

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

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

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

9.9. Describe the process used by the state to accomplish involvement of the public in

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

Effective Date: January 2005 Approval Date: June 2006 45 the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

The process of design and implementation of the CHIP was open to allow input and participation from various interested and affected parties. Initial decisions were reached during the 1998 Legislative session in which Legislators received input from recipients, providers, advocates, business community, medical care industry, religious, and political leaders. Phase I of CHIP was set forth in statute, together with a Commission to design Phase II. This law is attached as Attachment C and the Final Report of the Commission is in Attachment G. Phase I CHIP was publicized in the routine manner through the State of Mississippi's Administrative Procedures Act. The CHIP Commission was appointed, according to state statute, to develop proposals regarding benefits, funding, and eligibility of children. The CHIP Commission meetings were open to the public, as were the meetings of the three subcommittees established to develop recommendations with respect to structure, benefits and eligibility and outreach. Public hearings were held in four locations across the state, and an advance notice of these meetings was published in both the newspaper with statewide distribution as well as local papers. In addition, the Division of Medicaid authored news releases, editorials, and public service announcements on educational television and public radio. To date, information about and the application for the State's CHIP is available on the Internet at the Division of Medicaid's web page http://www.dom.state.ms.us. The Division has established statewide coalitions not only to assist with dissemination of MHB applications and materials but also to funnel families’ experiences and concerns to the Division. Finally, the Division has maintained an extensive mailing list, and all materials and updates developed are distributed ongoing to all included therein.

This application will be published in the routine manner through the State’s Administrative Procedures Act.

The Health Insurance Management Board meets on the fourth Tuesday of each month. These meetings are open to the public Notification of the time and place of the meetings is sent to all persons requesting such.

A statewide coalition of state agencies, community based health/social service agencies, and local advocacy associations has been formed. CHIP is their primary focus and there have been regular meetings at which DOM, DHS, SDH, DOE, DMH and DFA are active participants. The program is enhanced by their outreach activities which complement our own, and these meetings are on-going. This coalition provides on-going feedback to the state regarding barriers, resolutions and simplifications and the outreach and enrollment process of SCHIP.

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

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

Effective Date: January 2005 Approval Date: June 2006 46

Leadership of the Mississippi Band of Choctaw Indians was contacted directly to provide input into the program development and implementation. Communication is maintained with the leadership of the Indian tribes to provide updates and input into ongoing program development and implementation and resolution of identified barriers.

As previously mentioned, a coalition of local advocacy associations has been formed. CHIP is their primary focus and there have been regular meetings at which DOM, DHS, SDH, DOE, DMH and DFA are active participants. The program is enhanced by their outreach activities which complement our own, and these meetings are on-going.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in 42 CFR 457.65(b) through (d).

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. (Section 2107(d)) (42CFR 457.140)

The budget must describe: • Planned use of funds, including --

- Projected amount to be spent on health services;

- Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment.

• Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. The source of State funds to finance CHIP is the Health Care Expendable Trust Funds (Tobacco Funds)

SCHIP Budget Plan STATE OF MISSISSIPPI

FFY 2004

FFY 2005

FFY 2005

FFY 2005

FFY 2006

Federal Fiscal Year Fourth Year Costs

Fifth Year PE Costs

Fifth Year Non-PE Costs Federal Fiscal Year Fifth Year Costs TOTALS

Federal Fiscal Year Sixth Year Costs

Benefit Costs

Insurance payments

117,824,291 0 132,282,082 132,282,082 154,380,000

Managed care

per member/per month rate @ # of eligibles

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

Effective Date: January 2005 Approval Date: June 2006 47

Fee for Service

Total Benefit Costs

117,824,291 0 132,282,082 132,282,082 154,380,000

(Offsetting beneficiary cost sharing ayments) p

Net Benefit Costs

117,824,291 0 132,282,082 132,282,082 154,380,000

Administration Costs

Personnel and Travel

500,000 500,000 500,000 500,000

General administration

1,000,000 0 1,100,000 1,100,000 1,250,000

Contractors/Brokers (e.g., enrollment ontractors) c

1,250,000

1,300,000 1,300,000 1,500,000

Claims Processing

500,000 750,000 750,000 850,000

Outreach/marketing costs

100,000 50,000 50,000

75,000

Other

500,000 500,000 500,000 500,000

Total Administration Costs

3,850,000 0 4,200,000 4,200,000

4,675,000

10% Administrative Cost Ceiling

13,091,588 14,698,009 14,698,009 17,153,333

Federal Share (multiplied by nh-FMAP rate) e

102,157,735

0

114,590,356

114,590,356

132,333,760

State Share

19,516,556 0 21,891,726 21,891,726

26,721,240

TOTAL PROGRAM COSTS

121,674,291 0 136,482,082 136,482,082

159,055,000

Note: PE will not be implemented in MS. Other Costs: FY 2006 costs were estimated using 83,000 clients at $1,920 per client with administration estimated at about 3.1%. Benefits costs are net of cost sharing. CHIP does have co-pays, but the benefits sent to the providers are net of the co-pay. DOM pays a set fee.

Section 10. Annual Reports and Evaluations (Section 2108)

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

10.1.1.

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

10.2.

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

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

Effective Date: January 2005 Approval Date: June 2006 48

10.3.

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

Section 11. Program Integrity (Section 2101(a))

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

11.1

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

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related information) 11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.

Section 1128A (relating to civil monetary penalties) 11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.

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

Section12. Applicant and enrollee protections (Sections 2101(a))

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

Eligibility and Enrollment Matters

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

Mississippi has established written criteria for the delivery of benefits, the

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

Effective Date: January 2005 Approval Date: June 2006 49

determination of eligibility and for fair and equitable treatment, including the opportunity for recipients who have been adversely affected to be heard in a State administrative or appeal process. The State will administer the due process notification of adverse action relative to Title XIX. This process includes an opportunity for a fair hearing handled independently of the regional office eligibility and/or benefit decision level. Recipients may resolve any benefit decreases, terminations, or related issues through this method. All enrollees receive written information about the grievance and appeal procedures that are available to them.

Health Services Matters

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

Denials related to health care services are appealed to the health plan. The final level of appeal is to an independent review entity external to the health plan. All levels of review must be completed within the required 90 day period.

Premium Assistance Programs

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

MISSISSIPPI TITLE XXI PROGRAM FACT SHEET

Name of Plan: Mississippi Title XXI

Date Plan Submitted:

July 29, 1998 Date Plan Approved:

October 26, 1998 Date Plan Effective:

July, 1998

Date Amendment #1 Submitted: August 4, 1998 Date Amendment #1 Approved:

February 10, 1999 Date Amendment #1 Effective:

January 1, 2000

Date Amendment #2 Submitted: September 22, 1999 Date Amendment #2 Approved:

December 17, 1999 Date Amendment #2 Effective:

January 1, 2000

Date Amendment #3 Submitted: July 6, 2000 Date Amendment #3 Approved:

October 2, 2000 Date Amendment #3 Effective:

October 1, 2000

Date Amendment #4 Submitted: July 3, 2001 Date Amendment #4 Approved:

October 5, 2001 Date Amendment #4 Effective:

July 1, 2001

Date Amendment #5 Submitted:

September 30, 2002 Date Amendment #5 Approved:

December 19, 2002

Date Amendment #6 Submitted:

December 29, 2005 Date Amendment #6 Approved:

June 2, 2006 Date Amendment #6 Effective:

January 1, 2005

Date Amendment #7 Submitted:

December 8, 2010 Date Amendment #7 Approved:

May 5, 2011 Date Amendment #7 Effective:

July 1, 2010

Background

• On July 29, 1998, Mississippi submitted a title XXI State plan (Phase I) to expand Medicaid to children born before October 1, 1983, in families with incomes above the State Medicaid levels and below 100 percent of the Federal Poverty Level (FPL). Note: This group of children aged out of the SCHIP Medicaid expansion October 1, 2002, and the State no longer has a SCHIP Medicaid expansion program. Amendments

• The State submitted its first State Children’s Health Insurance Program (SCHIP) state plan amendment on August 4, 1998, for a separate child health program (Phase II). It covered children below age 19 in families with income levels between 100 percent and 133 percent of the FPL who were not eligible to participate in Phase I. It also proposed a premium assistance program for children with access to employer- sponsored coverage. Note: The State has not yet implemented the premium assistance program. • A second amendment was submitted by the State on September 22, 1999. This amendment expanded the income eligibility to 200 percent of the FPL in the separate child health program and introduced cost sharing requirements. • On July 6, 2000, Mississippi submitted its third state plan amendment to eliminate the required 6-month period of uninsurance for children with previous creditable health insurance coverage in the separate child health program. The 6-month period of uninsurance will continue to apply in the premium assistance program. • A fourth amendment was submitted by the State on July 3, 2001. This amendment to the separate child health program provides presumptive eligibility for children in families with income at or below 200 percent FPL. Note: The State has chosen not to implement this option. • Mississippi submitted its fifth amendment on September 30, 2002, to update its state plan to indicate compliance with the final SCHIP regulations. • A sixth amendment was submitted by the State on December 29, 2005. This amendment requires a face-to-face interview at application and redetermination of eligibility, requires verification of birth for all applicants, provides a 12-month period of continuous eligibility, and removes language authorizing the State to determine eligibility presumptively. (The State never implemented the previously granted authority.) • The State submitted its seventh amendment on December 8, 2010 to come into compliance with the mental health parity requirements in section 502 of the Children’s Health Insurance Program Reauthorization Act (CHIPRA). The amendment has a retroactive effective date of July 1, 2010.

Children Covered Under the Program • The State reported that 95,556 children were ever enrolled in its program during Federal fiscal year 2010.

Administration

• The program is administered by the State and Public School Employees Health Insurance Management Board, which is also referred to as the Health Insurance Management Board. An outreach contractor supports and augments the outreach activities of the State.

Health Care Delivery System

• Health care is delivered primarily through managed care organizations.

Benefit Package

• The State provides benchmark coverage equivalent to the benefit package offered under the Network Option of the State and Public Employer’s Health Insurance Plans plus additional benefits such as immunizations, vision and hearing screening and dental services. • With amendment number 7, the State eliminated the maximum benefit amount and service limits previously imposed on mental health and substance use disorder benefits, effective July 1, 2010.

Cost Sharing • Copayments are calculated on a sliding scale based on income levels: less than 150 percent of the FPL, no cost-sharing requirements; 151 to 175 percent of the FPL, $5 per outpatient health care professional visit, $15 per ER visit and $800 out-of- pocket maximum; 176 to 200 percent of the FPL, $5 per outpatient health care professional visit; $15 per ER visit and $950 out-of-pocket maximum.

Crowd-Out Strategy • Mississippi will monitor the number of children enrolled in SCHIP who had coverage within 6 months of application. If the data indicates that 15 percent of the enrolled children have dropped insurance coverage within 6 months prior to applying, the State will propose additional crowd-out strategies.

Outreach Activities • The State utilizes a number of measures to identify and enroll children. These include: o Partnering with entities and programs through local and State inter-agency councils, school-based health programs, and community organizations. o Utilizing community health care providers, hospitals, health clinics, Indian reservations and school-based EPSDT providers to identify potentially eligible individuals for education and distribution of materials.

Coordination Between SCHIP and Medicaid

• The State utilizes a joint application form.

• Eligibility is determined in the same manner and by the same agency as eligibility for Medicaid. If applicants are determined ineligible for Medicaid, they will be considered for SCHIP eligibility.

Financial Information

Total FFY ‘11 CHIP allotment -- $160.648,691 FFY ‘11 Enhanced Federal matching rate –82.97%

Last updated on May 27, 2011

_____________________________________________________________________________

Table of Contents

State/Territory Name: Mississippi

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

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 Mississippi 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 Cc M Ss

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

Children and Adults Health Programs Group

MAR 14 2014

Janis Bond

Bureau of Enrollment

Office of the Governor, Division of Medicaid Suite 1000 Walter Sillers Building

550 High Street

Jackson, MS 39201

Dear Ms. Bond:

Iam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number MS-13-0009, submitted on December 20, 2013, and related Modified Adjusted Gross Income (MAGI) Eligibility, with an effective date of January 1, 2014.

In this SPA, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low-income children. 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. Also, a copy of the approved CS7 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. Where the current CHIP state plan contains relevant information, the new pages should replace and supersede the corresponding information throughout the current state plan.

Your title XXI project officer is Ms. LaVern Baty. She is available to answer questions concerning this amendment. Ms. Baty’s 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) 786-5480

Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator in our Atlanta Regional Office. Ms. Glaze’s address is:

Page 2 — Ms. Janis Bond

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Federal Center, 4" Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

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:

Jackie Glaze, ARA, CMS Region IV

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MS.0642.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Mississippi State Funds: $ 0.00 Federal Funds: $ 0.00 Submitted By: Margaret Wilson 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. MS-13-0009 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 2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320 Federal Budget Impact This SPA has a budget impact. Total budget impact: Please attach a revised CHIP budget. Document Subject of Amendment Please provide a brief summary of SPA changes. Character Count:107 out of 2000 CHIP MAGI Eligibility and Methods CS7 - Targeted Low-Income Children CS15 - MAGI-Based Income Methodologies Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/10/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Last Revision Date: Feb 12, 2014 Submit Date: Dec 20, 2013 FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/10/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Cems CHIP Eligibility

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

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

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

The CHIP Agency operates this covered group in accordance with the following provisions: Age Must be under age 19.

Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard? Statewide Income Standards [Begin with lowest age range first. Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here. From Age To Age Above (% FPL) Up to & including (% FPL) + flo 1 194 209 xX +h 6 143 209 “xX oF lie 19 133 209 Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards. From birth up to but not including age 1 the standard is income greater than 194% FPL up to & including 209% FPL. From age 1 up to but not including age 6 the standard is income greater than 143% FPL up to & including 209% FPL. From age 6 up to but not including age 19 the standard is income greater than 133% up to & including 209% FPL.

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities?

MAR—+-4-2014

SPA# MS-13-0009 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

ccmMs CHIP Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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

MAR 1 4 2014

SPA# MS-13-0009 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

ccMs. CHIP Eligibility

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

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

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

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

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

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: @ The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. C The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: 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. No

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.

An attachment is submitted.

PRA Disclosure Statement

SPA# MS-13-0009 Approval Date: MAR i 4 2014 Effective Date: January 1, 2014

Page 1 of 2

CccMs. 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.

SPA# MS-13-0009 Approval Date: MAR { 4 mig Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Mississippi

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

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

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

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

Children and Adults Health Programs Group

FEB 13 2014

Janis Bond

Bureau of Enrollment

Office of the Governor, Division of Medicaid Suite 1000 Walter Sillers Building

550 High Street ;

Jackson, MS 39201

Dear Ms. Bond:

I am writing to inform you that your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbered MS-13-0010 submitted on December 20, 2013, and related to Modified Adjusted Gross Income (MAGI) Eligibility has been approved with an effective date of January 1, 2014.

SPA number MS-13-0010 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is enclosed, and this 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.

Your title XXI project officer is Ms. Lavern Baty. She is available to answer questions concerning this amendment. Ms. Baty’s contact information is as follows:

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

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

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to

Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region 4, Ms. Jackie Glaze, Division of Medicaid and Children’s Health Operations.

Page 2 — Ms. Janis Bond Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Federal Center, 4" Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

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: Jackie Glaze, ARA, CMS Region IV Sheila Chavis, Office of the Governor, Division of Medicaid

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MS.0643.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Mississippi State Funds: $ 0.00 Federal Funds: $ 0.00 Submitted By: Margaret Wilson 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. MS-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(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Please attach a revised CHIP budget. Document Subject of Amendment Please provide a brief summary of SPA changes. Character Count:191 out of 2000 XXI Medicaid Expansion CS3 - Set MAGI-based income standards for CHIP Medicaid Expansions, Establish new Medicaid eligibility group for 6-18 year olds with incomes between 100-133% of the FPL Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/10/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Last Revision Date: Dec 20, 2013 Submit Date: Dec 20, 2013 FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/10/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

coms CHIP Eligibility

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

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

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

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL)

lle 19 107 133 >

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 13 2014

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

_____________________________________________________________________________

Table of Contents

State/Territory Name: Mississippi

State Plan Amendment (SPA) #: MS-13-0011

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

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop: 2-01-16 « M Ss Baltimore, Maryland 21 244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 1 1 2014

Ms. Janis Bond

Bureau of Enrollment

Office of the Governor, Division of Medicaid Suite 1000 Walter Sillers Building

550 High Street

Jackson, MS 39201

Dear Ms. Bond:

Iam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XX] Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbered MS-13-0011 submitted on December 20, 2013, and related Modified Adjusted Gross Income (MAGI) Eligibility with an effective date of January 1, 2014.

SPA number MS-13-0011 describes the state’s plan to provide coverage in its separate CHIP, for children subject to Section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Mississippi’s approved CHIP state plan.

Your title XXI project officer is Ms. Lavern Baty. She is available to answer questions concerning this amendment. Ms. Baty’s contact information is as follows:

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

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

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to

Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region 4, Ms. Jackie Glaze, Division of Medicaid and Children’s Health Operations. Ms. Glaze’s address is:

Page 2 — Ms. Janis Bond

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Federal Center, 4" Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

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 Enclosure ce:

Jackie Glaze, ARA, CMS Region IV

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MS.0644.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Mississippi State Funds: $ 0.00 Federal Funds: $ 0.00 Submitted By: Margaret Wilson 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. MS-13-0011 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Please attach a revised CHIP budget. Document Subject of Amendment Please provide a brief summary of SPA changes. Character Count:152 out of 2000 Establish 2101(f) Group CS14 - Establish new coverage for group of children who lose Medicaid eligibility as a result of discontinuation of disregards. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/10/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Last Revision Date: Dec 20, 2013 Submit Date: Dec 20, 2013 FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/10/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CEMS __ CHIP Eligibility

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

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

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

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

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

@

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

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

ay 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

c would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

(% FPL

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

C Other.

Describe the benefits provided to this population:

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

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

Describe premiums and cost sharing required of this population:

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

SPA# MS-13-0011 Approval Date: MAR L L 2014 Effective Date: January 1, 2014 Page 1 of 2

coms CHIP Eligibility

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

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

(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.

SPA# MS-13-0011 Approval Date: . MAR 1 | 2014

Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Mississippi

State Plan Amendment (SPA) #: MS-13-0012

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 Mississippi 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 CRA Ss 7500 Security Boulevard, Mail Stop: S2-26-12

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES Children and Adults Health Programs Group MAY 05 2014 Janis Bond Division of Medicaid

Bureau of Enrollment

Suite 1000 Walter Sillers Bldg. 550 High Street

Jackson, MS 39201

Dear Ms. Bond:

I am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved Mississippi’s Children’s Health Insurance Program (CHIP) state plan amendment (SPA), MS-13-0012 submitted on December 20, 2013. 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.

The approval of SPA MS-13-0012 includes full approval of your state’s alternative single streamlined paper application. The state is using an interim alternative single streamlined online application (PDF) and by December 31, 2014, will implement a revised alternative single streamlined online application that addresses CMS concerns as outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following CS24 state plan pages and attachments to be incorporated within a separate section at the end of Mississippi’s approved state plan:

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

e Attachment 1 — State of Mississippi alternative single streamlined paper 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

Page 2 — Ms. Janis Bond

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

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) 786-5480

Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator (ARA) in our Atlanta Regional Office. Ms. Glaze’s address is:

Ms. Jackie Glaze

Office of the Regional Administrator Atlanta Federal Center

61 Forsyth Street, SW, Suite 4T20 Atlanta, Georgia 30303-8909

If you have additional questions, please contact Barbara K. Richards, Acting Director, Division of State Coverage Programs at 410-786-5920.

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

Sincerel

Eliot Fishman Director

Enclosure

ce: Ms. Jackie Glaze, Associate Regional Administrator, CMS Atlanta Region

DEPARTMENT OF HEALTH & HUMAN SERVICES (CMS

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop: 82-26-12 CM 4 CENTERS FOR MEDICARE & MEDICAID SERVICES:

Children and Adults Health Programs Group

MAY 05 2014

Janis Bond

Division of Medicaid

Bureau of Enrollment

Suite 1000 Walter Sillers Bldg. 550 High Street

Jackson, MS 39201

RE: CS24 — Eligibility Process State Plan Amendment (SPA), MS-13-0012 Dear Ms. Bond:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of Mississippi’s state plan amendment (SPA) transmittal MS-13-0012, which was submitted to CMS on December 20, 2013. Our review of this submission included a review of the state’s online and paper alternative single streamlined applications.

Until December 31, 2014, the state is using an interim alternative single streamlined online application. This application must be revised to meet the standards outlined in 42 CFR 435.907 and the guidance on alternative applications released by CMS on June 19, 2013.

Please submit the revised alternative single streamlined online application to CMS no later than December 1, 2014, to allow time for review prior to December 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Victoria Collins at Victoria.Collins@cms.hhs.gov or (410) 786-2167.

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

Sincerel: ~ Acting Director Division of State Coverage Programs

ce: Ms. Jackie Glaze, Associate Regional Administrator, CMS Atlanta Region

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MS.0645.R00.00 - Oct 01, 2013 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Mississippi State Funds: $ 0.00 Federal Funds: $ 0.00 Submitted By: Margaret Wilson 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. MS-13-0012 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(3) and 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: Please attach a revised CHIP budget. Document Subject of Amendment Please provide a brief summary of SPA changes. Character Count:151 out of 2000 Eligibility Process CS24 - Single, Streamlined Application, Screen and Enroll Process, Renewals and Screening by Other Insurance Affordability Programs 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

Last Revision Date: May 9, 2014 Submit Date: Dec 20, 2013 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

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

0) Paper Application 1 Online Application

TRANSMITTAL NUMBER: STATE: |

MS-13-0012 Mississippi

Through December 31, 2014, the state is using an interim online alternative single streamlined application. After December 31, 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. The revised application will be incorporated by reference into the state plan.

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

a 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.

BR An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with 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 [C] agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

wi 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.

Other electronic means:

Name of method Description fax Applications received by fax will be accepted e-mail Applications received via e-mail will be accepted

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

SPA# MS-13-0012 Approval Date: MAY 0 5 2014 Effective Date: October 7, 2013

Page 1 of 2

CHIP Eligibility

Procedures include:

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

iw 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 programs based on household income; and

a 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 No premium tax credits in accordance with section 1943(b)(2) of the SSA.

Redetermination Processing

wl 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;

[i] Once every 12 months.

ial 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 [il 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

a 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 oO insurance affordability programs as provided in 42 CF R 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 Oo 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.

MAY G5 201%

SPA# MS-13-0012 Approval Date: Effective Date: October 1, 2013 Page 2 of 2

f,

+ MISSISSIPP! DIVISION OF

MISSISSIPPI APPLICATION FOR HEALTH BENEFITS MEDICAID

(MEDICAID, CHIP, HELP PAYING COSTS FOR HEALTH INSURANCE COVERAGE)

This application is used to apply for health coverage for:

© Medicaid

¢ CHIP (Children’s Health Insurance Program)

e The new tax credit that.can help pay your health insurance premiums

e Private health insurance plans through a federal Health Insurance

Marketplace

Use this application to apply for children, pregnant women, low-income parents of children under age 18 and anyone in your family that needs to apply for health coverage. If you need this

application in a language other than English or if you are hearing or visually impaired and need special assistance, contact 1-800-421-2408.

You do not have‘to fill out this application on paper. If you choose, you can apply on-line at www.predicaid.ms.goyv or are.zov.

What you will need to apply: © Social Security Numbers or document numbers for legal immigrants who need insurance, © Birth dates, ¢ Employer and income information for each person in your family with income. Use income from paystubs or W-2 forms or any document that shows exactly what each person receives as income, ¢ Policy numbers for any current health insurance, * Information about any job-related health insurance available to your family. We will keep all the information you provide private, as required by law.

Complete and sign this application and send it to the address below. If you have questions, call 1-800-421-2408 for assistance. ‘

REGIONAL MEDICAID OFFICE ADDRESS & PHONE NUMBER

Cover Sheet Issue Date 10/01/2013

APPENDIX A TO MISSISSIPPI APPLICATION FOR HEALTH COVERAGE HEALTH COVERAGE FROM JOBS

If someone in the household is eligible for health coverage from a job, please complete this form. Complete this form for each job that offers coverage, using separate forms for each job. Take this form to the employer to help complete the health coverage questions if needed. Complete the form for each household member eligible for health coverage through a job, even if it is from another person’s job, like a spouse or parent of a child under age 26,

Name of employee: SSN:

Employer Information | Employer ID # (EIN)

Name of Employer:

Address of Employer:

City State Zip Phone # | Email

Contact Person Regarding Health Coverage:

Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? __ Yes (Continue) __ No (Stop here)

If you are in a waiting period or probationary period, when can you enroll in coverage?

List the names of anyone else who is eligible for coverage from this job.

Name:

Name:

Name:

Tell us about the health plan offered by this employer:

Does the employer offer a health plan that covers an employee’s spouse or dependent? o No cYes— which people? a Spouse o Dependent

Does the employer offer a health plan that meets the minimum value standard? o Yes o No An employer-sponsored health plan meets the minimum value standard if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60% of such costs (Sec. 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

For the lowest cost plan that meets the minimum value standard offered only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.

Employee premiums for this plan $. . How often?

What change will the employer make for the new plan year (if known)?

u Employer will not offer health coverage

o Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard (premium should reflect the discount for wellness programs). Premium amount $ How often?

Date of change: Appendix A — Employer Coverage (Issue Date 10/01/2013)

PART I - HEAD OF HOUSEHOLD — This is the primary adult contact for this application. We will -

contact you for any additional questions we may have. You do not have to apply for health Coverage to be the primary contact.

Full Name Home Address

City State Zip County Mailing Address

City State Zip County Phone Numbers — (home) (cell)

(work) (message #)

Do you want to get information about this application by email? 1 Yes C1 No If yes, provide email address;

Preferred spoken or written language (if not English)

PART 2 — AUTHORIZED REPRESENTATIVE (Optional) — You can name a person you trust to act as your authorized representative. This means you are giving this person permission to see your application and to act for you on matters relating to this application, including providing information needed to complete this application. You must complete and sign this portion of the application to name someone to act for you. If someone is legally appointed to act for you, submit proof with this application.

Name of Representative

Address (include Apt or Lot #)

City State Zip Phone # Relationship to Head of Household

Organization Name ID# (if applicable)

By signing, you allow this person to sign your application, get official information about this application and act for you in all future matters related to the health coverage of the ones applying:

Signature of Head of Household Date

Part 1 & Part 2 (revised 07/01/2014)

PART 3 - HOUSEHOLD MEMBERS - Include everyone who lives with you, even if not applying. If you file a federal tax return, include everyone that you include on your federal tax return, even if they do

not live with you. Person 1 is the head of household for this application.

Name

Social Security Number*

Date of Birth

Sex: Male Female

How is this person related to you?

Is this person applying?

SELF

OYes OINo

OYes CINo

OYes CINo

OYes ONo

ClYes CINo

OYes CINo

{Yes CINo

(Yes CINo

WO} coh LE AL a] BY] Wl dO]

OYes No

= o

ClYes ONo

*Social Security Numbers (SSN) — We need SSN’s for everyone who-has one and is applying for health coverage, You are not required to provide an SSN for household members not applying but it will speed up the application process if you do give us SSN’s of everyone. We use SSN’s to check income and other information to see who is eligible for help with health coverage. If you need help getting an SSN, contact Social Security at 1-800-772-1213. TTY users call 1-800-325-0778. Or visit socialsecurity.gov.

PART 4 —- RETROACTIVE MEDICAID COVERAGE (not available to children qualifying for CHIP) If determined eligible for Medicaid, does any household member applying need Medicaid to cover services received within the last 3 months? (1 Yes [1 No If yes, complete the following:

Name of household members/months needed:

PART 5 —- HEALTH INSURANCE INFORMATION - If anyone applying for health coverage currently has health insurance, tell us about it. This includes Medicaid, CHIP, Medicare, and coverage through VA health programs, private coverage, work, a retiree health plan or any type of health insurance.

Name of Person

Type of Coverage

Name of Health Plan

Policy Number

Part 3, Part 4 & Part 5 (revised 07/01/2014)

PART 6 — INFORMATION NEEDED ON HOUSEHOLD MEMBERS — please complete the following information on all household members listed in Part 3.

Person 1 — This is the person named as Head of Household

Name —

(first) (middle/maiden) (last) (suffix)

Are you pregnant? [1 Yes [1 No If yes, what is the expected date of delivery? How many babies are expected?

Do you plan to file a federal income tax return next year? [1 Yes CINo Ifyes, select your filing status: O Married Filing Jointly [] Married Filing Separately OI Individual DJ Head of Household O Qualifying Widow(er) If filing jointly with spouse, name of spouse

Will you claim any dependents on your tax return? 01 Yes CI No If yes, name of dependents claimed:

Will you be claimed as a dependent on someone’s tax retum? 1 Yes 1 No If yes, name of tax filer: How are you related to tax filer?

Do you need health coverage? [] Yes If yes, answer all questions below. CNe Ifno, skip to “Current Job and Income Information” on next page.

Do you have a physical, mental or emotional health condition that limits common activities like bathing, dressing, daily chores, etc. or do you live in a medical facility or nursing home? 0 Yes C1 No If you are disabled, would you like to apply for Medicaid as a disabled person? C1 Yes C1No Ifyes, you will be asked to complete additional forms to determine if you qualify for Medicaid as a disabled individual. :

Are you a United States citizen or U. S. National? (1 Yes (1No If no, complete the following: Immigration status (such as lawful permanent resident, refugee, asylee, etc.) Immigration document type and ID number Have you lived in the U.S. since 1996 (1 Yes [No Are you or your spouse or parent a veteran or an active- duty member of U.S. military? [Yes 1) No

Do you live with at least one child under the age of 18 and are you the main person taking care of this child? 0 Yes C1No If yes, name of child(ren) Do any of the children named have a parent living outside the home? (1 Yes (1 No If yes, you will be asked to cooperate with child support services to collect medical support from the absent parent unless child support services determines you have good cause not to cooperate,

Were you in foster care at age 18 or older? C1 Yes C1 No If yes, in what state?

Race (optional) check all that apply: [] White 11 Black O American Indian or Alaska Native 1 Chinese O Asian Indian 1 Filipino C1 Japanese 01 Korean 0) Vietnamese 1] Other Asian ( Native Hawaiian 1 Samoan (1 Guamanian or Chamorro (1 Other Pacific Islander 0 Other

If Hispanic/Latino, check all that apply (optional) (] Mexican 1 Mexican-American Chicano/a

(1 Puerto Rican O Cuban £1] Other

Part 6 / Person 1 (revised 07/01/2014)

Person 1 — continued

Current Job & Income Information: Are you currently:

0 Employed— How many jobs?__——s—s«1 Self-employed —- How many jobs?____-—«(1. Unemployed Job #1: Employer Name

Employer Address & Phone:

Wages/tips (before taxes) $ O) Hourly O Weekly C1 Every 2 weeks 0 Twice month Monthly [1 Yearly Average hours worked each week ___—_—Start Date of employment

Job #2: Employer Name

Employer Address & Phone:

Wages/tips (before taxes) $ O Hourly O Weekly 0 Every 2 weeks 11 Twice month 1 Monthly (1 Yearly Average hours worked each week Start Date of employment

Self-employment — type of work

How much net income (profit after expenses allowed by the IRS) will you get from this self-employment? $ How often is this income received?

In the past year, did you: O Change jobs [1 Stop Working [1 Start Working Fewer Hours 1 Other Explain: .

Other Income ~ Tell us about other income that you receive that is not the result of your current employment. Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest, Dividends, Rental income, Royalties,

Type of Benefit Amount Paid (before How Often Received? | Start Date of Payment deductions) $

$

$

If you are eligible for certain benefits, such as Unemployment Compensation, you must apply in order to be eligible for Medicaid.

Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted toward your household income, but it helps us to know if you get these income types to support your family. Check here if you get any of these income types: 1

Deductions from income — certain deductions allowable on a federal tax return are allowed to be deducted from your reported income (unless already deducted from income shown above). If you pay alimony, student loan.

interest or have other allowable deductions, tell us what they are: Type Amount Paid $ How Often?

Yearly Income — complete if your income changes from month to month: What is your total income for this calendar year? $ Next year (if different) $

Part 6 / Person 1 continued (revised 07/01/2014)

Person 2 — give us information on person #2 listed in Part 3: Household Members

Does this person live at the same address with the head of household? [1 Yes 1 No

Name —

(first) (middle/maiden) (last) (suffix)

Is this person pregnant? C1 Yes CINo If yes, what is the expected date of delivery? How many babies are expected?

Does this person plan to file a federal income tax return next year? [] Yes [1 No If yes, select filing status: C] Married Filing Jointly 11 Married Filing Separately C1 Individual (1 Head of Household Ci Qualifying Widow(er) If filing jointly with spouse, name of spouse

Will this person claim any dependents on their tax retun? C1 Yes CI No If yes, name of dependents claimed:

Will this person be claimed as a dependent on someone’s tax return? [1] Yes C1No If yes, name of tax filer: Relationship to tax filer?

Does this person need health coverage? [Yes If yes, answer all questions below. CINo Ifno, skip to “Current Job and Income Information” on next page.

Does this person have a physical, mental or emotional health condition that limits common activities like bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? ( Yes CINo If disabled, would this person like to apply for Medicaid as a disabled person? (1 Yes (1 No

If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.

Is this person a United States citizen or U. S. National? (1 Yes [1 No If no, complete the following: Immigration status (such as lawful permanent resident, refugee, asylee, etc.) Immigration document type and ID number Has this person lived in the U.S. since 1996 [1 Yes [1 No Is this person or their spouse or parent a veteran or an active-duty member of U.S. military? O Yes 01 No

Does this person live with at least one child under the age of 18 and is this person the main person taking care of this child? C1 Yes [1 No If yes, give names of child(ren) Do any of the children named have a parent living outside the home? (1 Yes C1 No If yes, this person will be asked to cooperate with child support services to collect medical support from the absent parent unless child support services determines there is good cause not to cooperate.

Was this person in foster care at age 18 or older? C1 Yes C1 No If yes, in what state?

Race (optional) check all that apply: 1] White 1 Black 1 American Indian or Alaska Native (Chinese 1) Asian Indian O Filipino C1 Japanese [] Korean (1 Vietnamese 1] Other Asian O Native Hawaiian 1] Samoan 1 Guamanian or Chamorro 1] Other Pacific Islander 1 Other

If Hispanic/Latino, check all that apply (optional) 1] Mexican 1) Mexican-American 01 Chicano/a C1 Puerto Rican 0 Cuban 0 Other

Part 6 / Person 2 (revised 07/01/2014)

Person 2 — continued

Current Job & Income Information: Is this person currently:

Oi Employed —-How many jobs?___—« 1 Selfemployed—How many jobs?___—«. Unemployed Job #1: Employer Name

Employer Address & Phone:

Wages/tips (before taxes) $ OHourly 0 Weekly D1 Every 2 weeks 0 Twice month O Monthly (1 Yearly Average hours worked each week Start Date of employment,

Job #2: Employer Name

Employer Address & Phone:

Wages/tips (before taxes) $ O Hourly 0 Weekly (1 Every 2 weeks (1 Twice month (Monthly (1 Yearly Average hours worked each week Start Date of employment

Self-empl it — type of work

How much net income (profit after expenses allowed by the IRS) will this person get from this self- employment? $ How often is this income received?

In the past year, did this person: [J Change jobs 1 Stop Working CO Start Working Fewer Hours O Other- Explain any changes:

Other Income — Tell us about other income that this person receives that is not the result of current employment. Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest, Dividends, Rental income, Royalties.

Type of Benefit Amount Paid (before How Often Received? | Start Date of Payment deductions)

$

$

$

If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in order to be eligible for Medicaid.

Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted toward household income, but it helps us to know if this person gets these income types to help support the family. Check here if this person gets any of these income types: 0

Deductions from income — certain deductions allowable on a federal tax return are allowed to be deducted from reported income (unless already deducted from income shown above). If this person pays alimony, student loan interest or has other allowable deductions, tell us what they are: Type

Amount Paid $ How Often?

Yearly Income — complete if income changes from month to month: What is this person’s total income for this calendar year? $ Next year (if different) $

Part 6 / Person 2 continued (revised 07/01/2014)

Person 3 — give us information on person #3 listed in Part 3: Household Members

Does this person live at the same address with the head of household? (J Yes 11 No

Name —

(first) (mniddle/maiden) (last) (suffix)

Is this person pregnant? C1 Yes (1 No If yes, what is the expected date of delivery? How many babies are expected?

Does this person plan to file a federal income tax retum next year? C1 Yes [No If yes, select filing status: C1 Married Filing Jointly 1] Married Filing Separately CI Individual 1) Head of Household CO Qualifying Widow(er) If filing jointly with spouse, name of spouse

Will this person claim any dependents on their tax return? C1 Yes [1 No If yes, name of dependents claimed:

‘Will this person be claimed as a dependent on someone’s tax return? C1 Yes C1No If yes, name of tax filer: Relationship to tax filer

Does this person need health coverage? 1 Yes If yes, answer all questions below. CINo Ifno, skip to “Current Job and Income Information” on next page.

Does this person have a physical, mental or emotional health condition that limits common activities like bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? 0 Yes ONo If disabled, would this person like to apply for Medicaid as a disabled person? (1 Yes [1 No

If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.

Is this person a United States citizen or U. S. National? (1 Yes C1No If no, complete the following: Immigration status (such as lawful permanent resident, refugee, asylee, etc.) Immigration document type and ID number Has this person lived in the U.S. since 1996 [1 Yes (1 No Is this person or their spouse or parent a veteran or an active-duty member of U.S. military? 11 Yes 1 No

Does this person live with at least one child under the age of 18 and is this person the main person taking care of this child? 0 Yes 1 No If yes, names of child(ren) Do any of the children named have a parent living outside the home? 0 Yes 0 No Ifyes, this person will be asked to cooperate with child support services to collect medical support from the absent parent unless child support services determines there is good cause not to cooperate.

Was this person in foster care at age 18 or older? O1 Yes C1No Ifyes, in what state?

Race (optional) check all that apply: (J White [J Black 0 American Indian or Alaska Native (1 Chinese C Asian Indian CD Filipino 1 Japanese (1 Korean (1 Vietnamese 1 Other Asian O Native Hawaiian 0 Samoan [1 Guamanian or Chamorro C1 Other Pacific Islander 0 Other

If Hispanic/Latino, check all that apply (optional) [1 Mexican 1] Mexican- American © Chicano/a 1] Puerto Rican [1 Cuban 1 Other

Part 6 / Person 3 (revised 07/01/2014)

Person 3 — continued Current Job & Income Information: Is this person currently:

0] Employed — How many jobs?____—ss« 1 Self-employed How many jobs? ___—«L], Unemployed Job #1: Employer Name

Employer Address & Phone:

Wages/tips (before taxes) $ OC) Hourly 01 Weekly C1 Every 2 weeks 1) Twice month O Monthly (1 Yearly Average hours worked each week Start Date of employment

Job #2: Employer Name Employer Address & Phone:

Wages/tips (before taxes) $ O Hourly (1 Weekly 0 Every 2 weeks 0 Twice month O) Monthly [1 Yearly Average hours worked each week__ Start Date of employment

Sel lo — type of work

How much net income (profit after expenses allowed by the IRS) will this person get from this self- employment? § How often is this income received?

In the past year, did this person: [1 Change jobs 0 Stop Working C1 Start Working Fewer Hours CQ) Other- Explain any changes:

Other Income — Tell us about other income that this person receives that is not the result of current employment. Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest, Dividends, Rental income, Royalties.

Type of Benefit Amount Paid (before How Often Received? Start Date of Payment deductions)

$

$

$

If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in order to be eligible for Medicaid.

Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted toward your household income, but it helps us to know if this person gets these income types to help support the family. Check here this person gets any of these income types: (1

Deductions from income — certain deductions allowable on a federal tax return are allowed to be deducted from reported income (unless already deducted from income shown above). If this person pays alimony, — student loan interest or has other allowable deductions, tell us what they are: Type

Amount Paid $ How Often?

Yearly Income — complete if income changes from month to month: What is this person’s total income for this calendar year? $ Next year (if different) $

Part 6 / Person 3 continued (revised 07/01/2014)

Person 4 — give us information on person #4 listed in Part 3: Household Members

Does this person live at the same address with the head of household? C1 Yes DJ No

Name —

(first) (middle/maiden) (last) (suffix)

Is this person pregnant? C1 Yes (1 No Ifyes, what is the expected date of delivery? How many babies are expected?

Does this person plan to file a federal income tax return next year? [Yes [No If yes, select filing status: 1 Married Filing Jointly C1 Married Filing Separately 1] Individual 1) Head of Household CO Qualifying Widow(er) If filing jointly with spouse, name of spouse

Will this person claim any dependents on their tax return? [1 Yes 1) No If yes, name of dependents claimed: .

Will this person be claimed as a dependent on someone’s tax return? [] Yes 1.No If yes, name of tax filer: Relationship to tax filer?

Does this person need health coverage? [1 Yes Hfyes, answer all questions below. CINo Ifno, skip to “Current Job and Income Information” on next page.

Does this person have a physical, mental or emotional health condition that limits common activities like bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? LC] Yes CNo If disabled, would this person like to apply for Medicaid as a disabled person? [1 Yes CINo If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.

Is this person a United States citizen or U. S. National? (1 Yes (1 No If no, complete the following: Immigration status (such as lawful permanent resident, refugee, asylee, etc.) Immigration document type and ID number

Has this person lived in the U.S. since 1996 [1 Yes [1 No Is this person or their spouse or parent a veteran or an active-duty member of U.S. military? 1 Yes 1 No

Does this person live with at least one child under the age of 18 and is this person the main person taking care of this child? 11 Yes [1 No If yes, name of child(ren) Do any of the children named have a parent living outside the home? 01 Yes 1) No If yes, this person will be asked to cooperate with child support services to collect medical support from the absent parent unless child support services determines there is good cause not to cooperate.

Was this person in foster care at age 18 or older? 1 Yes No If yes, in what state?

Race (optional) check all that apply: 1 White (1 Black O American Indian or Alaska Native (1) Chinese 0 Asian Indian 0 Filipino 0 Japanese (J Korean 0 Vietnamese CO Other Asian C Native Hawaiian 1 Samoan C] Guamanian or Chamorro () Other Pacific Islander 1) Other

If Hispanic/Latino, check all that apply (optional) 1 Mexican 1] Mexican- American O Chicano/a 0 Puerto Rican 11 Cuban 0 Other

Part 6 / Person 4 (revised 07/01/2014)

Person 4 — continued

Current Job & Income Information: Is this person currently:

0 Employed—How many jobs?___—s—«1 Self-employed - How many jobs?__—s« (1) Unemployed

Job #1: Employer Name

Employer Address & Phone:

Wages/tips (before taxes) $ O Hourly O Weekly O Every 2 weeks (1 Twice month

O Monthly 0 Yearly Average hours worked each week Start Date of employment. Job #2: Employer Name

Employer Address & Phone:

Wages/tips (before taxes) $ O Hourly () Weekly 1] Every 2 weeks (1 Twice month O Monthly (1 Yearly Average hours worked each week __ Start Date of employment

Self-employment — type of work

How much net income (profit after expenses allowed by the IRS) will this person get from this self- employment? §. How often is this income received?

In the past year, did this person: [1 Change jobs C1 Stop Working (1 Start Working Fewer Hours 0 Other- Explain any changes:

Other Income — Tell us about other income that this person receives that is not the result of current employment. Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest, Dividends, Rental Income, Royalties.

Type of Benefit Amount Paid (before How Often Received? | Start Date of Payment deductions)

$

$

$

If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in order to be eligible for Medicaid.

Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted toward your household income, but it helps us to know if this person gets these income types to help support the family. Check here if this person gets any of these income types: 0

Deductions from income — certain deductions allowable on a federal tax retum are allowed to be deducted from reported income (unless already deducted from income shown above). If this person pays alimony, student loan interest or has other allowable deductions, tell us what they are: Type

Amount Paid $ How Often?

Yearly Income ~ complete if income changes from month to month: What is this person’s total income for this calendar year? $ Next year (if different) $

Part 6 / Person 4 continued (revised 07/01/2014)

Person # — continued Current Job & Income Information: Is this person currently: (1 Employed — How many jobs? O Self-employed — How many jobs? O Unemployed

Job #1: Employer Name

Employer Address & Phone:

Wages/tips (before taxes) $ O Hourly C1 Weekly C] Every 2 weeks 1 Twice month Cl Monthly 0 Yearly Average hours worked each week Start Date of employment,

Job #2: Employer Name Employer Address & Phone:

Wages/tips (before taxes) $ ____O Hourly 0 Weekly 1 Every 2 weeks (J Twice month 1 Monthly 0 Yearly Average hours worked each week Start Date of employment.

Self-employment — type of work

How much net income (profit after expenses allowed by the IRS) will this person get from this self- employment? $ How often is this income received?

In the past year, did this person: C] Change jobs [1 Stop Working C1 Start Working Fewer Hours 0 Other- Explain any changes:

Other Income — Tell us about other income that this person receives that is not the result of current employment. Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest, Dividends, Rental Income, Royalties.

Type of Benefit Amount Paid (before How Often Received? Start Date of Payment deductions) $

$

$ If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in order to be eligible for Medicaid.

Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted toward household income, but it helps us to know if this person gets these income types to help support the family. Check here if this person gets any of these income types: 1

Deductions from income — certain deductions allowable on a federal tax return are allowed to be deducted from your reported income (unless already deducted from income shown above). If this person pays alimony, student loan interest or has other allowable deductions, tell us what they are: Type

Amount Paid $ How Often?

Yearly Income — complete if income changes from month to month: What is this person’s total income for this calendar year? $ Next year (if different) $

Part 7 / Additional Person continued (10/01/2013)

Person #. ~ give us information on the next person listed in Part 3: Household Members

Does this person live at the same address with the head of household? 01 Yes [1 No

Name —

(first) (middle/maiden) (last) (suffix) Date of Birth - (mm/dd/yyyy) . Sex- O) Male O Female

Is this person pregnant? O1Yes C1No Ifyes, what is the expected date of delivery? How many babies are expected?

Does this person plan to file a federal income tax return next year? C1 Yes ONo If yes, select filing status: C] Married Filing Jointly (1 Married Filing Separately (1 Individual 1] Head of Household 0 Qualifying Widow(er). If filing jointly with spouse, name of spouse

Will this person claim any dependents on their tax retum? (1 Yes 0 No If yes, name of dependents claimed:

Will this person be claimed as a dependent on someone’s tax return? [1 Yes C1 No If yes, name of tax filer: Relationship to tax filer?

Does this person need health coverage? [1 Yes If yes, answer all questions below. ONo § Ifno, skip to “Current Job and Income Information” on next page.

Does this person have a physical, mental or emotional health condition that limits common activities like bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? [1] Yes No If disabled, would this person like to apply for Medicaid as a disabled person? [1 Yes [1 No

If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.

Is this person a United States citizen or U. S. National? (1 Yes (JNo_ Ifno, complete the following: Immigration status (such as lawful permanent resident, refugee, asylee, etc.) Immigration document type and ID number Has this person lived in the U.S. since 1996 [1] Yes 1 No Is this person or their spouse or parent a veteran or an active-duty member of U.S. military? 0 Yes [1 No

Does this person live with at least one child under the age of 18 and is this person the main person taking care of this child? 10 Yes 11 No If yes, name of child(ren) Do any of the children named have a parent living outside the home? [1 Yes (1 No If yes, this person will be asked to cooperate with child support services to collect medical support from the absent parent unless child support services determines there is good cause not to cooperate.

‘Was this person in foster care at age 18 or older? (1 Yes [1 No If yes, in what state?

Race (optional) check all that apply: [] White (1 Black OC American Indian or Alaska Native O Chinese 0 Asian Indian 0 Filipino C1 Japanese (1 Korean 1 Vietnamese ( Other Asian Native Hawaiian (J Samoan ( Guamanian or Chamorro (1 Other Pacific Islander Other

If Hispanic/Latino, check all that apply (optional) [1 Mexican 01 Mexican- American (] Chicano/a 0 Puerto Rican 11 Cuban 0 Other

Part 7 / Additional Person (10/01/2013)

PART 7 —- ACCESS TO HEALTH INSURANCE

Is anyone in the household offered health coverage from a job? This includes health coverage the person could get through their job, someone else’s job (such as a parent or spouse) and includes private employer plans, TRICARE, federal or state employee plans or any type of employer health coverage.

O Yes C1No If yes, you will need to complete Appendix A. Is this a state employee’s benefit plan? 0 Yes O No

PART 8 - COMPLETE ONLY IF ANY HOUSEHOLD MEMBERS ARE AMERICAN INDIAN OR ALASKAN NATIVE. If no, skip to Part 9.

American Indians and Alaskan Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. You may also not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the

most help possible.

Name Name Name

Member of Federally Recognized | Member of Federally Recognized | Member of Federally Recognized Tribe? O Yes (No Tribe? O Yes O1No Tribe? O Yes 1 No

If yes, name tribe: If yes, name tribe: If yes, name tribe:

Has this person ever gotten a Has this person ever gotten a Has this person ever gotten a service from the Indian Health service from the Indian Health service from the Indian Health Service, a tribal health program | Service, a tribal health program | Service, a tribal health program or through a referral from one of | or through a referral from one of | or through a referral from one of

these programs? [1 Yes [1 No

these programs? (1 Yes 0 No

these programs? (1 Yes 1 No

Tfno, is this person eligible to get services from the Indian Health Service, tribal health programs or through a referral from one of these programs? 1] Yes 0 No

If no, is this person eligible to get services from the Indian Health Service, tribal health programs or through a referral from one of these programs? 1 Yes [1 No

If no, is this person eligible to get services from the Indian Health Service, tribal health programs or through a referral from one of these programs? (1 Yes 11 No

If you have more people to include, make a copy of this page and attach.

Certain money received may not be counted for Medicaid or CHIP. Tell us if any of the income reported for any American Indian or Alaskan Native household member includes money from the following:

Per capita payments fromatribe | Cl Yes No Name of Person Receiving the that come from natural resources, | Amount $ Payment usage rights, leases or royalties? | How often? Payments from natural resources, | 0 Yes [] No Name of Person Receiving the farming, ranching, fishing, leases Payment or royalties from reservation land | Amount $ or Indian trust land? How often? Money from selling things that C Yes 0No Name of Person Receiving the have cultural significance? Amount $ Payment

How often?

Part 7 & 8 (revised 07/01/2014)

PART 9- READ & SIGN THIS APPLICATION ~ continued

We need information on this application form to check your eligibility for help paying for health coverage if you choose to apply. We'll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security and/or a consumer reporting agency. If the information does not match, we may ask you to send us proof.

To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the federal health insurance marketplace to use income data, including information

from tax returns. The marketplace will send me a notice, let me make any changes and I can opt out at any time,

Yes, renew my eligibility automatically (if possible) for the next: [1 5 years (maximum) or for O14 years (13 years (12 years [11 year 1 Don’t use information from tax returns to renew my coverage.

Your Right to Appeal

If you think that the Health Insurance Marketplace or Medicaid or CHIP made a mistake, you can appeal the decision. To appeal means to ask for a hearing or review of the action taken that you think is wrong. You can find out how to appeal any action taken by the federal health insurance marketplace or Medicaid/CHIP by calling 1-800-421-2408. You can be represented by someone other than yourself. Your eligibility and other important information will be explained to you. A change in your information reported on your application or review form could affect the eligibility of all household members applying or receiving benefits through the Marketplace or Medicaid or CHIP.

Sign This Application

Signature of Head of Household or Authorized Representative Date (month, day, year)

Do you want to register to vote? [1 Yes ) No Ef yes, complete the attached voter registration form and return it with this application.

lete this section if you are a

Part 9 continued & Signature (revised 07/01/2014)

PART 9- READ & SIGN THIS APPLICATION

* Pm signing this application under penalty of perjury which means I’ve provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide false and/or untrue information.

¢ Tknow that I must report to Medicaid or the federal health insprance marketplace if anything

” changes and is different from what I wrote on this application. I understand that a change in my information could affect the eligibility for member(s) of my household. To report changes: Call 1-800-421-2408 or report in petson or by calling your local Medicaid Regional Office.

© I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age or disability, I can file a complaint of discrimination by visiting www. hhs.gov/ocr/office/file,

¢ [confirm that no one applying for health insurance on this application is incarcerated (in jail).

If anyone applying is eligible for Medicaid or CHIP, you need to know and agree to the following:

If Medicaid pays for a medical expense, any money from other health insurance or legal settlements will go to Medicaid to reimburse for these services. By accepting Medicaid, you agree to give up your rights to any third party payments to the Division of Medicaid.

If you receive care or treatment under Medicaid or CHIP, you authorize the health care provider to release to Medicaid or the CHIP insurer your medical recards and information relating to your diagnosis, examination and treatment. ©

Your case will be reviewed every year and you will be sent a notice regarding the action you must take, if any, to renew Medicaid or CHIP coverage. Adults may be reviewed more than once per year depending on the types of changes that are reported during the year.

Information that you give may be selected for review by state or federal auditors (reviewers). You must cooperate with the review process if your case is selected. No additional permission is needed to get verification or other information. to review your case.

Children under age 21 who are eligible for Medicaid are eligible for a free health care prevention program. It provides a way for children to get medical exams, check-ups, follow up treatment and special care to make sure they maintain good health. You will be asked to select an approved screening provider once your children are enrolled in Medicaid.

Adults eligible for Medicaid should get a yearly health screening (physical exam) from your local doctor or clinic. This exam will not count against your annual doctor visit limit.

Information about family planning services and WIC food services are available from your local Health Department.

Part 9 (revised 07/01/2014)

_____________________________________________________________________________

Table of Contents

State/Territory Name: Mississippi

State Plan Amendment (SPA) #: MS-13-0013

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

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

7500 Security Boulevard, Mail Stop: 52-01-16 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

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

Ms. Janis Bond

Bureau of Enrollment

Office of the Governor, Division of Medicaid Suite 1000 Walter Sillers Building

550 High Street

Jackson, MS 39201

Dear Ms. Bond: °

MAR 0 3 2014

1 am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) numbered MS-13-0013 submitted on December 20, 2013, and related Modified Adjusted Gross Income (MAGI) Eligibility with an effective date of January 1, 2014.

The SPA number MS-13-0013 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, and continuous eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of Mississippi’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

Section 4.1.9.1

Security Number

C820: Non-Financial Eligibility — Substitution | Section 4.4.4 of Coverage

C827: General Eligibility - Continuous Section 4.1.8 Eligibility

Your title XXI project officer is Ms. Lavern Baty. She is available to answer questions concerning this amendment. Ms. Baty’s 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) 786-5480 Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Page 2 ~ Ms. Janis Bond

Official communications regarding program matters should be sent simultaneously to

Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region 4, Ms. Jackie Glaze, Division of Medicaid and Children’s Health Operations. Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Féderal Center, 4" Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

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: Jackie Glaze, ARA, CMS Region IV

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MS.0651.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Mississippi State Funds: $ 0.00 Federal Funds: $ 0.00 Submitted By: Margaret Wilson 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. MS-13-0013 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 Sections 2105(a)(4)(A) and 2110(b)(1)(C) of the SSA; 42 CFR 435.926, 457.310(b)(2) and (b)(3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Please attach a revised CHIP budget. Document Subject of Amendment Please provide a brief summary of SPA changes. Character Count:135 out of 2000 Non-Financial Eligibility CS17 - Residency CS19 - Social Security Number CS20 - Substitution of Coverage CS27 - Continuous Eligibility Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/10/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Last Revision Date: Feb 24, 2014 Submit Date: Dec 20, 2013 FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 04/10/2014 http://157.199.113.99/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

CEMS—_._« CHIP Eligibility

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

42 CFR 457.320

Residency

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:

ia 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. [] 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

[ll 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 a residence.

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

rT 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

iw 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

iw A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

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

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CccmMs. CHIP Eligibility

One or more interstate agreement(s). No

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

Provide a description of the policy:

If in the state only to attend school for a temporary period with no intent to reside, CHIP coverage is not possible.

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

SPA# MS-13-0013 Approval Date:__MAR ft 3 2014 Effective Date: January 1, 2014 Page 2 of 2

cems CHIP Eligibility

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

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

Citizenship

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

{ii] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

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

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

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

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

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

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

C Other date, as described:

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

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 N also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- °

Income Pregnant Women. MAR 03 2014

SPA# MS-13-0013 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

Cems. CHIP Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number, The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 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.20130917

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cemMs CHIP Eligibility

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

e

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.

i 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 Ves SSN.

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

ry] 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# MS-13-0013 Approval Date: MAR 0 3 2014

Effective Date: January 1, 2014 Page 1 of 2

ccms. 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.

MAR 0 3 2014

SPA# MS-13-0013 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

coms CHIP Eligibility

OMB Control Number: 0938-1148

457.3 10(b)(2) and (b)(3), 457.320(a)(9) and 2110(b)(1)(C) of the SSA

Expiration date: 10/31/2014

Substitution of Coverage

[i] Substitution of coverage prevention strategy:

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

Name of policy

Description

other creditable health coverage

Total CHIP denials are monitored monthly. If the total number of CHIP denials for having other insurance exceeds 10% for 3 consecutive months, this triggers additional monitoring of the denials for the months that exceeded 10% to identify the number of children denied for other insurance subsequently

in CHIP during this 3-month period exceeds 15%, there will be an analysis of case record information to determine if there has been a qualifying event recorded that is responsible for the dropped coverage,

a change of jobs with no access to insurance. At any time the 15% threshold is exceeded, MS would

collaborate with CMS to identify a strategy to reduce the substitution rate. There is no waiting period for children in MS CHIP.

enrolled in CHIP within the following 3 month period. |. If the number of denied children subsequently enrolled | °

such as the termination of coverage by an employer or |:

provided in section 2110(b)(5) of the SSA.

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

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

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

oO The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as

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

PRA Disclosure Statement

SPA# MS-13-0013 Approval Date:

MAR 0 3 2014

Effective Date: January 1, 2014

Page 1 of 2

Cems 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.

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Effective Date: January 1, 2014 Page 2 of 2

CEMS __ CHIP Eligibility

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

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

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

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

(@ For children up to age 19

(‘For children up to age

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

[lM Atthe endofthe [12 | months continuous eligibility period.

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

rr] 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.

[il] The child dies.

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

{(C] Other

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

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20130717

MAR 0 3 2014

SPA# MS-13-0013 Approval Date: Effective Date: January 1, 2014 Page 1 of 1

_____________________________________________________________________________ Table of Contents State/Territory Name: Mississippi State Plan Amendments (SPA) #: MS-18-0010-CHIP This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

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

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

Children and Adults Health Programs Group

NOV 1 3 2049

Mr. Drew L. Snyder

Executive Director

Office of the Governor, Division of Medicaid 550 High Street

Jackson, MS 39201

Dear Mr. Snyder:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) MS- 18-0010-CHIP submitted on January 9, 2018, with additional information submitted on November 13, 2019, has been approved. This SPA has an effective date of October 1, 2019.

SPA number MS-18-0010-CHIP permits Mississippi to implement a health services initiative (HSI) to improve the health of low-income children by increasing their access to needed vision services and glasses through a targeted, school-based initiative. The HSI will allow the state to provide these services on-site at Title I schools in which at least 51 percent of students receive free or reduced price meals. Services will be provided for uninsured children and children who lack insurance coverage for vision services. Services for children enrolled in Medicaid and CHIP will not be funded under the initiative; federal financial participation is available for vision services provided to these children through the regular Medicaid and CHIP claiming processes.

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

The state shall ensure that the remaining title XXI funding, within the state's 10 percent administrative limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of this HSI to the administration of the CHIP program.

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

Page 2 — Mr. Drew L. Snyder

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services, Mail Stop S2-01-16 7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-4554

E-mail: Cassandra.Lagorio@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Lagorio and to Ms. Davida Kimble, Acting Deputy Director, Division of Medicaid Field Operations South. Ms. Kimble’s address is:

Centers for Medicare & Medicaid Services Division of Medicaid Field Operations South 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 We look forward to continuing to work with you and your staff. Sincerely,

/signed Anne Marie Costello/

Anne Marie Costello ~ Director

cc: Ms. Davida Kimble, Acting Deputy Director, Division of Medicaid Field Operations South

SPA number: MS-18-0010-CHIP Approval Date: 11/13/19 Effective Date: 10/1/19 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: ____Mississippi_______________________________________________ (Name of State/Territory)

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

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

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

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

Name:Drew Snyder Position/Title: Executive Director, MS Div. of Medicaid Name: Janis Bond Position/Title: Deputy Administrator, Office of Enrollment Name: Jennifer Wentworth Position/Title: Deputy Administrator, Office of Finance Name: Tara Clark Position/Title: Deputy Executive Director

*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 09380707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA number: MS-18-0010-CHIP Approval Date: 11/13/19 Effective Date: 10/1/19

Insurance Program Reauthorization Act of 2009 (CHIPRA); clarification of enrollee coverage provided in an emergency department.

Amendment #9 submitted: February 9, 2015 Implemented January 1, 2015 To reflect the change in operation of the separate CHIP health plan to two (2) contracted MCOs.

Amendment #10 submitted: January 9, 2018 Implemented October 1, 2019 To include a Health Services Initiative offering vision services to low-income children throughout the state.

SPA number: MS-18-0010-CHIP Approval Date: 11/13/19 Effective Date: 10/1/19

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.

TN No 10: Effective Date 01/01/2018.

A notification letter with the draft CHIP SPA #10 was submitted to the Tribe on 12/15/2017, requesting an expedited review and submittal to CMS. The Tribe approved CHIP SPA #10 on 1/8/18.

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)

The Mississippi Division of Medicaid’s CHIP CCOs will enroll non-profit providers (qualified provider) enrolled in both Mississippi Medicaid and CHIP to offer vision services to low-income children throughout the state. These services will not be reimbursed if the child has reached his/her benefit limits regarding a vision screening, eye exam and/or glasses/frames during the fiscal year. The program description and requirements of the qualified providers are as follows:

• The qualified provider will target Mississippi’s low-income children by identifying Title I schools in which at least 51% of the student body qualifies to receive free or reduced price meals. In Mississippi, this includes 83% of schools statewide. The qualified provider will provide to the Division of Medicaid the list of schools where vision services will be provided. The Division of Medicaid’s CHIP CCO will verify that each school on the list meets the 51% threshold for free or reduced price meals. The qualified provider will initially implement this HSI program in schools with the largest schools with the highest percentage of students eligible for free/reduced lunch (FRL) program first and then expand to additional schools in the state who meet the HSI criteria. • The qualified provider will give all children in the targeted schools parental/guardian consent forms that require a parent/guardian’s signature to opt-in or decline the services. The school will maintain a list of which children have opted-in and which children will not receive the services. Those children who do not have an opt-in consent form returned to the school will not receive the services. • For children whose parents/guardians opt-in to receive the services, the qualified provider will perform one vision screening, one eye exam for those who fail the vision screening and, if needed, corrective lenses and frames, including replacements, as needed, on-site in a mobile eye clinic (for the eye exam) or within the school (for the vision screening and provision of glasses). • The qualified provider will maintain an electronic medical record for each child that it serves, which will include the name of the child, services received, and other available identifying information (for example, date of birth, phone number and address) collected via the consent form. The qualified provider will submit CMS-1500 claims to the appropriate CHIP/Medicaid coordinated care organization (CCO), or the Division of Medicaid. The CHIP/Medicaid CCOs will pay the qualified provider based on negotiated, standard fees. • The qualified provider will identify all children served aged 18 or younger who are not identified as enrolled in Medicaid fee-for-service, a Medicaid/CHIP CCO or as having private vision

SPA number: MS-18-0010-CHIP Approval Date: 11/13/19 Effective Date: 10/1/19

insurance. The qualified provider will submit these uninsured children’s information including at a minimum, the child’s name, date of birth, services provided and date of service to the Mississippi Division of Medicaid’s CHIP CCO which will remit payment to the qualified provider for these services through CHIP HSI funding. • The HSI will target only children/youth under the age of 19. • The Division of Medicaid assures this HSI will not supplant or match CHIP Federal funds with other Federal funds, nor allow other Federal funds to supplant or match CHIP Federal funds.

Mississippi estimates that approximately 2,500-3,000 children will receive services (an exam, and glasses as needed) through CHIP HSI funding on an annual basis. An updated budget is included in Section 9.10.

SPA number: MS-18-0010-CHIP Approval Date: 11/13/19 Effective Date: 10/1/19

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.

The Mississippi Division of Medicaid consults with the tribe by notifying the Mississippi Band of Choctaw Indians (MBCI) designees, in writing, with a description of the proposed changes and direct impact, at least thirty (30) days prior to each submission by the State of any CHIP SPA that is likely to have a direct effect on Indians, Indian Health programs, or Urban Indian Organizations (I/T/U) by email. MCBI designees are the Choctaw Health Center’s Deputy Director and the Director of Financial Services.. Direct impact is defined as any Medicaid or CHIP program changes that are more restrictive for eligibility determinations, changes that reduce payment rates or payment methodologies to Indian Health Programs, Tribal Organizations, or Urban Indian Organization providers, reductions in covered services, changes in consultation policies, and CHIP proposals that may impact I/T/U providers. If no response is received from the tribe within thirty (30) days, the Mississippi Division of Medicaid will proceed with the submission to the Centers for Medicare and Medicaid Services (CMS).

If the Mississippi Division of Medicaid is not able to consult with the tribe thirty (30) days prior to a submission, a copy of the proposed submission along with the reason for the urgency will be forwarded to the tribe designee. The Tribe may waive this notification time-frame requirement in writing via e-mail. If requested, a conference call with the MCBI designee and/or other tribal representatives will be requested to review the submission and its impact on the tribe. The Mississippi Division of Medicaid will then confirm the discussion via email and request a response from the designee to ensure agreement on the submission. This documentation will be provided as part of the submission information to CMS.

The Choctaw Health Center’s Deputy Health Director and Director of Financial Services were notified by e-mail on December 15, 2017, of the proposed CHIP #10 submission. An expedited submission was requested. The Tribe approved CHIP SPA #10 on 1/8/18.

9.10. Provide a 1-year projected budget. Budget submitted with MS SPA 18-0010-CHIP, effective

10/01/2019. Federal Fiscal Year 2020 Oct - Sept Projected Costs Enhanced FMAP rate 95.39% [Benefit Costs Insurance payments Managed care 156,220,634

per member/per month rate @ # of eligibles 277.59 PM/PM — 49,600 eligibles Risk Assessment State Share Only ($3)

Fee for Service 2.700.000 Total Benefit Costs 158,920,634 (Offsetting beneficiary cost sharing payments)

Net Benefit Costs 158,920,634 | Administration Costs

Personnel 3,242,025

General administration 300,000

Contractors/Brokers (e.g., enrollment contractors) -

Claims Processing

Outreach/marketing costs

Other

Health Services Initiative 288.000

Total Administration Costs 3.830.025

10% Administrative Cost Ceiling 17,657,848

Federal Share (multiplied by enhanced-FMAP rate) 155,247,854

State Share 7,502,8050

Note: The Federal Fiscal Year (FFY) runs from October 1st through September 30th.

SPA number: MS-18-0010-CHIP Approval Date: 11/13/19 Effective Date: 10/1/19

_____________________________________________________________________________ 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 Mississippi MS-19-0011-CHIP

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: 32-01-16 Baltimore, Maryland 21244-1850 Children and Adults Health curs ctNItRs roß MtDtc Rf, & MtDtcAlD sÉwtcÉs CINTER fOI M¡DICAID & CHIP Sf,TVIGES Group FEB 0 6 Z0Z0 Mr. Drew L. Snyder Executive Director Office of the Governor, Division of Medicaid 550 High Street Jackson, MS 39201 Dear Mr. Snyder: I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIP) State Plan Amendment (SPA) number MS- I 9-00 I I -CHIP submitted on May 7 , 2019, with additional information submitted on January 30,2020, has been approved. Through this SPA, Mississippi implements mental health parity requirements to ensure that financial requirements (FRs) and treatment limitations applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical (M/S) benefits, effective July 1,2018. Mississippi also removes the copayment on outpatient MH/SUD services effective November 1,2019. Section 2103(c)(7)(A) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457.496(d)(3)-(5), requires states that provide both M/S and MH/SUD benefits to ensure that FRs and treatment limitations applied to MH/SUD benefits covered under the state child health plan are consistent with mental health parity requirements of section 2705(a) of the Public Health Service Act, in the same manner which such requirements apply to a group health plan. Mississippi demonstrated compliance by providing the necessary assurances and supporting documentation that the state's application of FRs and non-quantitative treatment limitations to MH/SUD benefits are consistent with section 2103(c)(7)(A) of the Act. This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analyzed separately. Your title XXI project officer is Ms. Cassie Lagorio. She is available to answer your questions concerning this amendment and other CHlP-related matters. Ms. Lagorio's 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- I 850 Telephone: (410) 786-4554 E-mail: Cassandra.LagorioøDcms.hhs.qov

Page 2 - Mr. Drew L. Snyder We look forward to continuing to work with you and your staff. Sincerely, Amy Lutzky Acting Deputy Director /Signed by Amy Lutzky/

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 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: Mississippi (Name of State/Territory)

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

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

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

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

Name: Drew Snyder

Position/Title: Executive Director, MS Div. of Medicaid Name: Janis Bond

Position/Title: Deputy Administrator, Office of Enrollment Name: Jennifer Wentworth

Position/Title: Deputy Administrator, Office of Finance Name: Tara Clark

Position/Title: Deputy Executive Director

*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 09380707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018

Insurance Program Reauthorization Act of 2009 (CHIPRA); clarification of enrollee coverage provided in an emergency department.

Amendment #9 submitted: February 9, 2015 Implemented January 1, 2015 To reflect the change in operation of the separate CHIP health plan to two (2) contracted MCOs.

Amendment #10 submitted: January 9, 2018 Implemented: October 1, 2019 To include a Health Services Initiative offering expanded vision services to low-income children throughout the state.

Amendment #11 MS SPA 19-0011-CHIP

Submitted: May 5, 2019 To demonstrate compliance with the Mental Health Parity and Addiction Equality Act (MHPAEA) final rule.

Effective: July 1, 2018

Amendment #12: MS SPA 19-0012-CHIP Submitted: June 27, 2019 To include managed care requirements.

Effective: July 1, 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.

A notification letter with the draft CHIP SPA #11 was submitted to the Tribe on 3/18/2019. The Tribe had no comments.

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

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

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

International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

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

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act)provides that to the extent

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

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

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

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

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan. A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements.

Guidance: If only a subset of children are provided EPSDT benefits under the State child health plan, 42 CFR 457.496(b)(3) limits deemed compliance to those children only and Section 6.2.3- MHPAEA must becompleted as well as the required parity analysis for the other children.

6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

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

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

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

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

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

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

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

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) Guidance: For states seeking deemed compliance for their entire State child health plan population, please continue to Section 6.3. If not all of the covered populations are offered EPSDT,the State must conduct a parity analysis of the benefit packages provided to those populations. Please continue to 6.2.3- MHPAEA.

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

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

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

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

6.2.3.1 MHPAEA Please describe below the standard(s) used to place covered benefits into one of the four classifications.

Benefit Classification Standards Used Inpatient Inpatient benefits are applied per the benefit plan to a registered inpatient bed patient in a hospital. Outpatient Outpatient benefits are applied per the benefit plan to a patient who is not a registered inpatient bed patient of a hospital. Pharmacy Pharmacy benefits are applied per the benefit plan and evidence based clinical criteria for use of medication, regardless of behavioral health or medical diagnosis. Emergency Services covered in connection with a medical condition that occur suddenly and without warning with symptoms which are so acute and severe as to require immediate medical attention.

6.2.3.1.1 MHPAEA The State assures that:

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 The State has classified all benefits covered under the State plan into one of the four classifications. The same reasonable standards are used for determining the classification for a mental health or substance use disorder benefit as are used for determining the classification of medical/surgical benefits. 6.2.3.1.2- MHPAEA Does the State use sub-classifications to distinguish between office visits and other outpatient services?

Yes No

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

The sub-classifications are only used to distinguish office visits from other outpatient items and services, and are not used to distinguish between similar services on other bases (ex: generalist vs. specialist visits). Guidance: For purposes of this section, any reference to “classification(s)” includes sub-classification(s) in states using sub-classifications to distinguish between outpatient office visits from other outpatient services.

6.2.3.2 MHPAEA The State assures that:

Mental health/ substance use disorder benefits are provided in all classifications in which medical/surgical benefits are provided under the State child health plan. Guidance: States are not required to cover mental health or substance use disorder benefits (42 CFR 457.496(f)(2)). However if a state does provide any mental health or substance use disorder benefits, those mental health or substance use disorder benefits must be provided in all the same classifications in which medical/surgical benefits are covered under the State child health plan (42 CFR 457.496(d)(2)(ii).

Annual and Aggregate Lifetime Dollar Limits

6.2.4- MHPAEA A State that provides both medical/surgical benefits and mental health and/or substance use disorder benefits must comply with parity requirements related to annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. (42 CFR 457.496(c))

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 6.2.4.1- MHPAEA Please indicate whether the State applies an aggregate lifetime dollar limit and/or an annual dollar limit on any mental health or substance abuse disorder benefits covered under the State child health plan.

Aggregate lifetime dollar limit is applied Aggregate annual dollar limit is applied No dollar limit is applied Guidance: A monetary coverage limit that applies toall CHIP services provided under the State child health plan is not subject to parity requirements.

If there are no aggregate lifetime or annual dollar limits on any mental health or substance use disorder benefits, please go to section 6.2.5- MHPAEA.

6.2.4.2- MHPAEA Are there any medical/surgical benefits covered under the State child health plan that have either an aggregate lifetime dollar limit or an annual dollar limit? If yes, please specify what type of limits apply.

Yes (Type(s) of limit: No Guidance: If no aggregate lifetime dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate lifetime dollar limit on any mental health or substance use disorder benefits. If no aggregate annual dollar limit is applied to medical/surgical benefits, the State may not impose an aggregate annual dollar limit on any mental health or substance use disorder benefits.(42 CFR 457.496(c)(1))

6.2.4.3- MHPAEA. States applying an aggregate lifetime or annual dollar limit on medical/surgical benefits and mental health or substance use disorder benefits must determine whether the portion of the medical/surgical benefits to which the limit applies is less than one-third, at least one-third but less than two-thirds, or at least two-thirds of all medical/surgical benefits covered under the State plan (42 CFR 457.496(c)).The portion of medical/surgical benefits subject to the limit is based on the dollar amount expected to be paid for all medical/surgical benefits under the State plan for the State plan year or portion of the plan year after a change in benefits that affects the applicability of the aggregate lifetime or annual dollar limits. (42 CFR 457.496(c)(3))

The State assures that it has developed a reasonable methodology to calculate the portion of covered medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit, as applicable. Guidance: Please include the state’s methodology to calculate the portion of covered

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 medical/surgical benefits which are subject to the aggregate lifetime and/or annual dollar limit and the results as an attachment to the State child health plan.

6.2.4.3.1-MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to a lifetime dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3

6.2.4.3.2-MHPAEA Please indicate the portion of the total costs for medical and surgical benefits covered under the State plan which are subject to an annual dollar limit:

Less than 1/3 At least 1/3 and less than 2/3 At least 2/3 Guidance: If an aggregate lifetime limit is applied to less than one-third of all medical/surgical benefits, the State may not impose an aggregate lifetime limit on any mental health or substance use disorder benefits. If an annual dollar limit is applied to less than one-third of all medical surgical benefits, the State may not impose an annual dollar limit on any mental health or substance use disorder benefits (42 CFR 457.496(c)(1)).Skip to section 6.2.5-MHPAEA.

If the State applies an aggregate lifetime or annual dollar limit to at least one- third of all medical/surgical benefits,please continue below to provide the assurances related to the determination of the portion of total costs for medical/surgical benefits that are subject to either anannual or lifetime limit.

6.2.4.3.2.1- MHPAEA If the State applies an aggregate lifetime or annual dollar limit to at least1/3 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

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 limit for medical/surgical benefits must be consistent with42 CFR 457.496(c)(4)(i)(B) and 42 CFR 457.496(c)(4)(ii). Please include the state’s methodology and results as an attachment to the State child health plan.

6.2.4.3.2.2- MHPAEA If at least 2/3 of all medical/surgical benefits are subject to an annual or lifetime limit, the State assures either of the following (42 CFR 457.496(c)(2)(i)); (42 CFR 457.496(c)(2)(ii)):

The aggregate lifetime or annual dollar limit is applied to both medical/surgical benefits and mental health and substance use disorder benefits in a manner that does not distinguish between medical/surgical benefits and mental health and substance use disorder benefits; or The aggregate lifetime or annual dollar limit placed on mental health and substance use disorder benefits is no more restrictive than the aggregate lifetime or annual dollar limit on medical/surgical benefits. Quantitative Treatment Limitations

6.2.5- MHPAEA Does the State apply quantitative treatment limitations (QTLs) on any mental health or substance use disorder benefits in any classification of benefits? If yes, specify the classification(s) of benefits in which the State applies one or more QTLs on any mental health or substance use disorder benefits.

Yes (Specify: ) No Guidance: If the state does not apply any type of QTLs on any mental health or substance use disorder benefits in any classification, the state meets parity requirements for QTLs and should continue to Section 6.2.6 - MHPAEA. If the state does apply QTLs to any mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue.

6.2.5.1- MHPAEA Does the State apply any type of QTL on any medical/surgical benefits?

Yes No Guidance:If the State does not apply QTLs on any medical/surgical benefits, the State may not impose quantitative treatment limitations on mental health or substance use

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 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, theState must determine the portion of medical and surgical benefits in the classification which are subject to the limitation. More specifically, the State must determine the ratio of (a) the dollar amount of all payments expected to be paid under the State plan for medical and surgical benefits within a classification which are subject to the type of quantitative treatment limitation for the plan year (or portion of the plan year after a mid-year change affecting the applicability of a type of quantitative treatment limitation to any medical/surgical benefits in the class) to (b) the dollar amount expected to be paid for all medical and surgical benefits within the classification for the plan year. For purposes of this paragraph, all payments expected to be paid under the State plan includes payments expected to be made directly by the State and payments which are expected to be made by MCEs contracting with the State. (42 CFR 457.496(d)(3)(i)(C))

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above for each classification within which the State applies QTLs to mental health or substance use disorder benefits. (42 CFR 457.496(d)(3)(i)(E)) Guidance: Please include the state’s methodology and resultsas anattachment 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

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 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 level of a type of quantitative treatment limitation applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of quantitative treatment limitation applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the predominant level of that type which is applied by the State to medical/surgical benefits within the same classification. (42 CFR 457.496(d)(2)(i)) Guidance: If there is no single level of a type of QTL that exceeds the one-half threshold, the State may combine levels within a type of QTL such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the predominant level is the least restrictive level of the levels combined to meet the one-half threshold. (42 CFR 457.496(d)(3)(i)(B)(2))

Non-Quantitative Treatment Limitations

6.2.6- MHPAEA The State may utilize non-quantitative treatment limitations (NQTLs) for mental health or substance use disorder benefits, but the State must ensure that those NQTLs comply with all the mental health parity requirements. (42 CFR 457.496(d)(4));(42 CFR 457.496(d)(5))

6.2.6.1 – MHPAEA If the State imposes any NQTLs, complete this subsection. If the State does not impose NQTLs, please go to Section 6.2.7-MHPAEA.

The State assures that the processes, strategies, evidentiary standards or other factors used in the application of any NQTL to mental health or substance use disorder benefits are no more stringent than the processes, strategies, evidentiary standards or other factors used in the application of NQTLs to medical/surgical benefits within the same classification.

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 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.

6.2.6.2 – MHPAEA The State or MCE contracting with the State must comply with parity if they provide coverage of medical or surgical benefits furnished by out-of-network providers.

6.2.6.2.1- MHPAEA Does the State or MCE contracting with the State provide coverage of medical or surgical benefits provided by out-of-network providers?

Yes No Guidance: The State can answer no if the State or MCE only provides out of network services in specific circumstances, such as emergency care, or when the network is unable to provide a necessary service covered under the contract.

6.2.6.2.2- MHPAEA If yes, the State must provide access to out-of-network providers for mental health or substance use disorder benefits. Please assure the following:

The State attests that when determining access to out-of-network providers within a benefit classification, the processes, strategies, evidentiary standards, or other factors used to determine access to those providers for mental health/ substance use disorder benefits are comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used to determine access for out- of-network providers for medical/surgical benefits. Availability of Plan Information

6.2.7- MHPAEA The State must provide beneficiaries, potential enrollees, and providers with information related to medical necessity criteria and denials of payment or reimbursement for mental health or substance use disorder services (42 CFR 457.496(e)) in addition to existing notice requirements at 42 CFR 457.1180.

6.2.7.1- MHPAEA Medical necessity criteria determinations must be made available to any current or potential enrollee or contracting provider, upon request. The state attests that the following entities provide this information:

State

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 Managed Care entities Both Other

Guidance: If other is selected, please specify the entity. 6.2.7.2- MHPAEA Reason for any denial for reimbursement or payment for mental health or substance use disorder benefits must be made available to the enrollee by the health plan or the State. The state attests that the following entities provide denial information:

State Managed Care entities Both

Other

Guidance: If other is selected, please specify the entity.

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

8.2.1. Premiums: None

8.2.2. Deductibles: None

8.2.3. Coinsurance or copayments:

Requirement ≤150% FPL 151%-175% FPL 176% - 209% FPL

Per doctor visit None $5.00

$5.00

Per ER visit

None $15.00

$15.00

Out-of-Pocket N/A

$800.00

$950.00

Maximum

8.2.4. Other:

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 No cost sharing is applied to preventive services, including immunizations, well child care, routine preventive and diagnostic dental services, routine dental fillings, routine eye examinations, eyeglasses, or hearing aids.

There is no cost sharing for American Indian/Alaska Native children.

Effective 11/1/19, copayments will not be charged on outpatient mental health/substance use disorder (SUD) visits.

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

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.

No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3

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

8.4.1- MHPAEA There is no separate accumulation of cumulative financial requirements, as defined in 42 CFR 457.496(a), for mental health and substance abuse disorder benefits compared to medical/surgical benefits. (42 CFR 457.496(d)(3)(iii))

8.4.2- MHPAEA If applicable, any different levels of financial requirements that are applied to different tiers of prescription drugs are determined based on reasonable factors, regardless of whether a drug is generally prescribed for medical/surgical benefits or mental health/substance use disorder benefits. (42 CFR 457.496(d)(3)(ii)(A))

8.4.3- MHPAEA Cost sharing applied to benefits provided under the State child health plan will remain capped at five percent of the beneficiary’s income as required by 42 CFR 457.560 (42 CFR 457.496(d)(3)(i)(D)).

8.4.4- MHPAEA Does the State apply financial requirements to any mental health or substance use disorder benefits? If yes, specify the classification(s) of benefits in which the State applies financial requirements on any mental health or substance use disorder benefits.

Yes (Specify: inpatient, outpatient, prescription drugs, emergency room) No Guidance: For the purposes of parity, financial requirements include deductibles, copayments, coinsurance, and out of pocket maximums; premiums are excluded from the definition. If the state does not apply financial requirements on any mental health or substance use disorder benefits, the state meets parity requirements for financial

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018 requirements. If the state does apply financial requirements to mental health or substance use disorder benefits, the state must conduct a parity analysis. Please continue below.

Please ensure that changes made to financial requirements under the State child health plan as a result of the parity analysis are also made in Section 8.2.

8.4.5- MHPAEA Does the State apply any type of financial requirements on any medical/surgical benefits?

Yes No Guidance: If the State does not apply financial requirements on any medical/surgical benefits, the State may not impose financial requirements on mental health or substance use disorder benefits.

8.4.6- MHPAEA Within each classification of benefits in which the State applies a type of financial requirement on any mental health or substance use disorder benefits, theState must determine the portion of medical and surgical benefits in the class which are subject to the limitation.

The State assures it has applied a reasonable methodology to determine the dollar amounts used in the ratio described above (Section 6.2.5.2-MHPAEA) for each classification or within which the State applies financial requirements 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 of the parity analysis as an attachment to the State child health plan.

8.4.7- MHPAEA For each type of financial requirement applied to any mental health or substance use disorder benefits within a given classification, does the State apply the same type of financial requirement to at least two-thirds (“substantially all”) of all the medical/surgical benefits within the same classification? (42 CFR 457.496(d)(3)(i)(A))

Yes No Guidance: If the State does not apply a type of financial requirement to substantially all medical/surgical benefits in a given classification of benefits,the State may not impose financial requirements on mental health or substance use disorder benefits in that classification. (42 CFR 457.496(d)(3)(i)(A))

SPA: MS-19-0011-CHIP Approval Date: February 6, 2020 Effective Date: July 1, 2018

8.4.8- MHPAEA For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State must determine the predominant level (as defined in 42 CFR 457.496(d)(3)(i)(B)) of that type which is applied to medical/surgical benefits in the classification. For each type of financial requirement applied to substantially all medical/surgical benefits in a classification, the State assures:

The same reasonable methodology applied in determining the dollar amounts used in determining whether substantially all medical/surgical benefits within a classification are subject to a type of financial requirement also is applied in determining the dollar amounts used to determine the predominant level of a type of financial requirement applied to medical/surgical benefits within a classification. (42 CFR 457.496(d)(3)(i)(E)) The level of each type of financial requirement applied by the State to mental health or substance use disorder benefits in any classification is no more restrictive than the 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 financial requirement that exceeds the one-half threshold, the State may combine levels within a type of financial requirement such that the combined levels are applied to at least half of all medical/surgical benefits within a classification; the 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))

_____________________________________________________________________________ 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 Mississippi MS-20-0013-CHIP

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

July 28, 2020

Mr. Drew Snyder Executive Director Office of the Governor, Division of Medicaid 550 High Street Jackson, MS 39201

Dear Mr. Snyder:

Your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) MS- 20-0013-CHIP, submitted on January 31, 2020, has been approved. Through this SPA, Mississippi changes the type of coverage it provides to children from benchmark coverage at Section 2103(a)(1) of the Social Security Act (the Act) to Secretary-approved coverage at 2103(a)(4) of the Act. The state also makes technical updates throughout the SPA. This SPA has an effective date of November 1, 2019.

Your title XXI project officer is Jack Mirabella. They are available to answer questions concerning this amendment and other CHIP-related issues. Their 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) 786-2424

E-mail: Jack.Mirabella@cms.hhs.gov

We appreciate the efforts of your staff and share your goal of providing health care to low­ income, uninsured children through title XXI. Your cooperation is greatly appreciated. If you have any questions, please contact Meg Barry, Acting 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

Acting Deputy Director /Signed by Amy Lutzky/

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: ____Mississippi_______________________________________________ (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/______________________________________________________ (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: Drew Snyder

Position/Title: Executive Director, MS Div. of Medicaid Name: Janis Bond

Position/Title: Deputy Administrator, Office of Enrollment Name: Jennifer Wentworth

Position/Title: Deputy Administrator, Office of Finance Name: Tara Clark

Position/Title: Deputy Executive Director

*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 09380707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Insurance Program Reauthorization Act of 2009 (CHIPRA); clarification of enrollee coverage provided in an emergency department.

Amendment #9 submitted: February 9, 2015 Implemented January 1, 2015 To reflect the change in operation of the separate CHIP health plan to two (2) contracted MCOs.

Amendment #10 submitted: January 9, 2018 Implemented: October 1, 2019 To include a Health Services Initiative offering expanded vision services to low-income children throughout the state.

Amendment #11 submitted: May 7, 2019 Implemented: July 1, 2018 To demonstrate compliance with the Mental Health Parity and Addiction Equality Act (MHPAEA) final rule.

Amendment #12: MS SPA 19-0012-CHIP Effective Date: July 1, 2018 To include managed care requirements.

Amendment #13: MS SPA 20-0013-CHIP

Submitted: January 31, 2020 To change the benchmark from the Mississippi Effective: November 1, 2019 State and School Employee’s Health Insurance Plan to a Medicaid “like” State Plan

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.

Refer to Section 2.3-TC for consultation process.

A notification letter with the draft MS SPA 20-0013-CHIP was submitted to the Tribe on December 5, 2019. The Tribe questioned if the CCOs will be reimbursing the full encounter rate as listed in the Federal Register. The Tribe was informed that the CCOs will be reimbursing one (1) encounter per day at the current encounter rate published in the Federal Register for services rendered effective November 1, 2019.

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

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

Demographics

According to the latest available census reports, Mississippi's population is 2,986,530 (2017 Census).

According to the 2017 Census American Community Survey Tables for Health Insurance Coverage, there are 389,000 children currently under 200% of the Federal Poverty Level (FPL).

23.6% of the people in Mississippi are under the age of 18.

According to the 2017 Census reports, there are 747,000 (25%) children less than 19 years of age in the State of Mississippi.

For federal fiscal year (FFY) 2018, an average of 396,194 children under age 19 were enrolled in Medicaid or CHIP.

Medicaid Eligibles

As of July 2019, , there are at least 343,903 Mississippi children less than 19 years of age currently enrolled in Medicaid.

CHIP

Mississippi originally implemented CHIP in July 1998 with a Medicaid expansion program for children 15 to 18 years of age at 100% of the FPL. This phase of the program ended as of October 01, 2002. To date, the State's CHIP targets all children in the state below age 19 who are below 200% FPL, not eligible for Medicaid coverage, and have no other health coverage. According to the Census Bureau’s 2017 American Community Survey, there are 44,000 uninsured children in Mississippi less than 19 years of age and below 200% FPL who are not covered by Medicaid or CHIP. The goal is to assess these children for CHIP eligibility under a health coverage package. As of July 2019, 46,012 children were enrolled in CHIP.

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.

The Mississippi Division of Medicaid consults with the tribe by notifying the Mississippi Band of Choctaw Indians (MBCI) designees, in writing, with a description of the proposed changes and direct impact, at least thirty (30) days prior to each submission by the State of any CHIP SPA that is likely to have a direct effect on Indians, Indian Health programs, or Urban Indian Organizations (I/T/U) by email. MCBI designees are the Choctaw Health Center’s Deputy Director and the Director of Financial Services. Direct impact is defined as any CHIP program changes that are more restrictive for eligibility determinations, changes that reduce payment rates or payment methodologies to Indian Health Programs, Tribal Organizations, or Urban Indian Organization providers, reductions in covered services, changes in consultation policies, and CHIP proposals that may impact I/T/U providers. If no response is received from the tribe within thirty (30) days, the Mississippi Division of Medicaid will proceed with the submission to the Centers for Medicare and Medicaid Services (CMS).

If the Mississippi Division of Medicaid is not able to consult with the Tribe thirty (30) days prior to a submission, a copy of the proposed submission along with the reason for the urgency will be forwarded to the tribe designee. The Tribe may waive this notification time-frame requirement in writing via e-mail. If requested, a conference call with the MBCI designee and/or other tribal representatives will be held to review the submission and its impact on the tribe. The Mississippi Division of Medicaid will then confirm the discussion via email and request a response from the designee to ensure agreement on the submission. This documentation will be provided as part of the submission information to CMS.

The Choctaw Health Center’s Deputy Director and the Director of Financial Services were notified by e-mail on September 19, 2019, of the proposed MS SPA 20-0013 - CHIP submission. Draft pages were submitted on January 5, 2020.

While not required, the Mississippi Division of Medicaid is conducting quarterly meetings with the tribe to discuss proposed Medicaid and CHIP program changes and other topics as permitted by schedules. An in person meeting with the tribe was held on December 4, 2019, to discuss this proposed MS SPA 20-0013 – CHIP submission.

Section 4. Eligibility Standards and Methodology

4.0.

Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group:

4.1.

Separate Program Check all standards that will apply to the State plan. (42 CFR § 457.305(a) and 457.320(a))

4.1.0 Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option.

Social Security Administration (SSA) verification is the primary source used to verify citizenship for applying children. If citizenship cannot be successfully verified by SSA, documentation is requested for applying children. A 90-day reasonable opportunity period is granted to provide documentation, during which time benefits are granted if otherwise eligible.

4.1.1 Geographic area served by the Plan if less than Statewide:

4.1.2 Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group:

Birth to age 1 – 194% FPL to 209% FPL. Age 1 to age 6 – 133% FPL to 209% FPL. Age 6 to age 19 – 133% FPL to 209% FPL.

4.1.2.1-PC Age: _______________ through birth (SHO #02-004, issued November 12, 2002)

4.1.3 Income of each separate eligibility group (if applicable):

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through ________% of the FPL (SHO #02-004, issued November 12, 2002)

4.1.4 Resources of each separate eligibility group (including any standards relating to spend downs and disposition of resources):

4.1.5 Residency (so long as residency requirement is not based on length of time in state):

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

4.1.7 Access to or coverage under other health coverage:

Children with coverage under other creditable health coverage at the time of application and children who are eligible for Medicaid are not eligible for CHIP.

4.1.8 Duration of eligibility, not to exceed twelve (12) months:

Twelve (12) months from the effective date of coverage for CHIP or until the child reaches 19 years of age or otherwise loses protected eligibility under the continuous eligibility provision.

4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 457.310 and 457.320 that are not addressed above. For instance:

4.1.9.1 States should specify whether Social Security Numbers (SSN) are required.

4.1.9.2 Continuous eligibility

All CHIP and Medicaid children are granted twelve (12) continuous months of eligibility unless the child reaches age 19 or otherwise loses protected eligibility under the continuous eligibility provision.

4.1-PW

Pregnant Women Option (section 2112) The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

4.1- LR

Lawfully Residing Option (Sections 2107(e)(1)(J) and 1993(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following:

A child or pregnant woman shall be considered lawfully present if he or she is:

A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24);

(iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days; An alien who has been granted withholding of removal under the Convention Against Torture; A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J)); An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Elected for pregnant women. Elected for children under age _____.

4.1.1-LR The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, it has verified, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

4.1-DS

Supplemental Dental (Section 2103(c)(5) - A child who is eligible to enroll in dental-only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

4.2. Assurances The State assures by checking the box below that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102(b)(1)(B) and 42 CFR § 457.320(b))

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

4.2.2. Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. This applies to pregnant women included in the State plan as well as targeted low-income children. 4.2.3. These standards do not deny eligibility based on a child having a pre-existing medical condition. This applies to pregnant women as well as targeted low-income children.

4.2-DS Supplemental Dental Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR § 457.320(b))

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

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

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

4.3 Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section 2102)(b)(2)) (42 CFR §, 457.350)

Eligibility for CHIP is determined in the same manner and by the same agency and staff as eligibility for Medicaid. Effective January 1, 2014, the State utilizes an alternative single, streamlined application developed by the State in accordance with section 1413(b)(1)(B) of the Patient Protection and Affordable Care Act (PPACA), as amended, and approved by the Secretary. These applications are available at community health centers, Head Start, health department clinics, other providers of care, the local DHS offices, the Mississippi Division of Medicaid website, and may be submitted via the internet website described in 42 CFR § 435.1200(f), by telephone, via mail, in person, via fax, and via secure email.

The State provides twelve (12) months of continuous enrollment in CHIP until the child reaches age 19 or otherwise loses protected eligibility under the continuous eligibility provision. Renewal will be conducted via administrative review based on available electronic sources. If determination is not possible based on available sources, a pre-populated renewal form will be issued to the beneficiary.

4.3.1 Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(4)) (42 CFR §, 457.305(b))

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

4.3.2. Check if the State elects to provide presumptive eligibility for children that meets the requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR § 457.355)

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

4.3.3.1-EL Also indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

4.3.3.2-EL List the public agencies approved by the State as Express Lane agencies.

4.3.3.3-EL List the components/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option.

4.3.3.3-EL List the component/components of CHIP eligibility that are determined under the Express Lane.

4.3.3.4-EL Describe the option used to satisfy the screen and enrollment requirements before a child may be enrolled under title XXI.

4.4 Eligibility screening and coordination with other health coverage programs

States must describe how they will assure that:

4.4.1. Only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance (including access to a State health benefits plan) are furnished child health assistance under the plan.(Sections 2102)(b)(3)(A), 2110(b)(2)(B)) (42 CFR § 457.310(b), 42 CFR § 457.350(a)(1) and 42 CFR § 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women. Mississippi does not impose a waiting period for enrollment in CHIP. Enrollment in CHIP is possible in the month following the month coverage terminates from other creditable coverage.

4.4.2. Children found through the screening process to be potentially eligible for medical assistance under the State Medicaid plan are enrolled for assistance under such plan; (Section 2102)(b)(3)(B)) (42 CFR §, 457.350(a)(2)) Each child is screened for Medicaid eligibility first and if determined ineligible and the child is uninsured, is evaluated for CHIP enrollment.

4.4.3. Children found through the screening process to be ineligible for Medicaid are enrolled in CHIP; (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42 CFR § 431.636(b)(4))

Children are screened for Medicaid eligibility first and if determined ineligible (and otherwise uninsured), are evaluated for CHIP enrollment.

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

An applying child’s current insurance status must be reported at the time of application and annual review. If the CHIP CCOs discover that a claim submitted lists any other insurance coverage for an eligible CHIP child, the CCOs provide this information to the Mississippi State Office of the Division of Medicaid for further investigation. Pending the findings, CHIP eligibility may or may not be terminated.

4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premium assistance program, describe: 1) the minimum period without coverage under a group health plan. This should include any allowable exceptions to the waiting period; 2) the expected minimum level of contribution employers will make; and 3) how cost-effectiveness is determined.

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

4.4-EL The State should designate the option it will be using to carry out screen and enroll requirements:

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR § 457.350(a) and 42 CFR § 457.80(c). Describe this process.

The State is establishing a screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by the Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process.

Section 5. Outreach and Coordination

5.1. (formerly 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2. (Section 2102)(a)(2) (42 CFR § 457.80(b))

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

Medicaid and CHIP are the only public health insurance programs in the State of Mississippi for children. Health services are provided in Mississippi to uninsured and Medicaid enrolled children by private physicians, 82 Mississippi County Health Department clinics operating at 87 sites, 21 federally qualified health centers (FQHC), newly-funded school health nurses, and several Indian Health Service Clinics. In addition, CHIP provides specialty care to uninsured and Medicaid enrolled children with special health care needs. The Department of Mental Health (DMH) provides mental health services to children through their Community Mental Health Clinics on a sliding scale fee arrangement based upon the patient's declared income. Program information presentations are provided on an on-going basis to schools and Head Start programs in the state, inviting families to apply for health benefits (Medicaid or CHIP). Applications, pamphlets, flyers, and posters are widely distributed.

Mississippi State Department of Health (MSDH)

This agency administers services and programs for Medicaid recipients and uninsured families and children, such as, perinatal high risk management/infant services system (PHRM/ISS), women, infants and children (WIC), environmental protection, comprehensive reproductive health, newborn genetic screening, well child health services, immunizations, and disease tracking and outbreak management. MSDH operates a county health department system of 87 sites and 96 WIC distribution centers. MSDH partners with the Mississippi Division of Medicaid in providing targeted case management services for high risk pregnant women and infants and early intervention program for infants and toddlers who have developmental delays, or a birth condition that could cause a developmental delay. This agency is an integral part of the outreach system for identifying Medicaid and CHIP eligible children.

Mississippi Department of Human Services (DHS)

This agency provides programs and services to needy and disadvantaged individuals and families through Temporary Assistance for Needy Families (TANF), food stamps, employment/training programs, literacy programs, childcare programs, child abuse and neglect services, foster care and adoption services, child support and medical support enforcement services, and providing care and treatment for children properly committed to the agency's custody. With offices in all 82 counties, this agency is integral in targeting and enrolling Medicaid and CHIP eligible children.

Mississippi Department of Rehabilitation Services (MDRS)

This agency provides rehabilitation services to eligible disabled adults and children who are on Medicaid or who are uninsured. In addition, it currently processes and renders disability decisions on applications for Social Security Disability and Supplemental Security Income Disability and for the State's Medicaid blind and disabled coverage groups. This agency will be integral in identifying and referring children eligible for Medicaid and CHIP.

Department of Mental Health (DMH)

Individuals receive services from DMH in addition to the fourteen (14) public Community Mental Health Center regions and a network of private mental health, substance use treatment and intellectual and developmentally disabled service provider agencies.

These providers serve the Medicaid population, as well as the uninsured, particularly children and will be integral in identifying individuals who may be Medicaid or CHIP eligible and referring them to the Division of Medicaid who is responsible for determining eligibility for Medicaid and CHIP.

Mississippi Division of Medicaid (DOM)

The Mississippi Division of Medicaid provides a statewide system of medical assistance, health care, and remedial and institutional services under Titles XXI, XIX, and XVIII of the Social Security Act. In partnership with DHS, MSDH, and DMH, the Mississippi Division of Medicaid identifies and enrolls Medicaid eligible children. This partnership has been maintained and strengthened to identify and enroll CHIP eligible children. MSDH and DMH serve as providers of services to Medicaid/CHIP eligible children and to uninsured children. The Mississippi Division of Medicaid works with these agencies and a statewide coalition of other partners to identify, enroll, and retain eligible children for the Mississippi Medicaid and CHIP. Through this avenue, the Medicaid agency will be able to utilize the schools to identify Medicaid and CHIP eligible children. With out- stationed workers in FQHCs, disproportionate share hospitals (DSH) and MSDH Clinics, the Division of Medicaid will utilize these service providers to identify Medicaid and CHIP eligible children. The Medicaid agency will increase its reliance on primary care providers (PCP) to disseminate information about eligibility for both Medicaid and CHIP for children through its Medical Care Advisory Committee.

5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in health insurance programs that involve a public-private partnership:

N/A

5.2. (formerly 2.3) Describe how CHIP coordinates with other public and private health insurance programs, other sources of health benefits coverage for children, other relevant child health programs, (such as title V), that provide health care services for low-income children to increase the number of children with creditable health coverage. Section 2102(a)(3) and 2102(c)(2) and 2102(b)(3)(E))(42 CFR § 457.80(c)). This item requires a brief overview of how Title XXI efforts -- particularly new enrollment outreach efforts will

be coordinated with and improve upon existing State efforts described in Section 5.2.

As discussed previously, there are no other public or private programs designed to provide creditable coverage for low-income children. The Mississippi Division of Medicaid has on- going communications with private health insurance groups, is present at their professional meetings, provides program information and updates, and has an exchange of referrals.

5.2-EL The State should include a description of its election of the Express Lane eligibility option to provide a simplified eligibility determination process and expedited enrollment of eligible children into Medicaid or CHIP.

N/A

5.3 Strategies

Outreach

Medicaid and CHIP applications and information are distributed statewide through health care providers and a statewide coalition of collaborative partners. Through these providers and collaborative partners, families are informed of the availability of coverage under Titles XIX and XXI. Outreach activities consist of efforts to identify and enroll children who are eligible for both Medicaid and CHIP. As previously discussed, Medicaid and CHIP are the only public health insurance programs for children in the state, and there is currently no private health coverage for children who cannot afford to pay for it. Thus, Medicaid and CHIP enrollment represent the only viable public alternatives for the State's children to have creditable insurance coverage in this targeted population. The State recognizes the importance of outreach to families of children likely to be eligible for assistance and to encourage them to enroll and retain their children, the State has done the following:

(a) Reduced barriers to participation by using the alternative single, streamlined application as described in PPACA. (b) Engaged in provider education efforts because providers are a vital link to this population; (c) Initiated cooperative efforts with MSDH, DHS, DMH, and MDRS regarding public awareness of these two programs; (d) Developed statewide coalitions to assist with the dissemination of materials and conducting a variety of outreach strategies such as health fairs and forums, development of informational fliers, posters, and other promotional items; (e) Engaged the print and radio media as a means to educate providers; (f) Coordinated a number of community based initiatives to educate families with potentially eligible children; (g) Partnered with entities and programs through local and state inter-agency councils, school-based health programs, and other community organizations whose missions include services to families and children; and (h) Out-stationed Medicaid specialists at FQHCs, Disproportionate Share Hospitals, County Health Departments, and Indian reservations. Beyond administering outreach, the State will ensure that staff at the appropriate state agencies will be well-trained to respond to inquiries from the public and provide progress reports to advocacy groups, the Legislature, and other interested parties.

Special Populations

The State works continuously with the Native American and Asian populations with the Medicaid and CHIP programs. The State has out stationed Medicaid specialists at Native Americans’ Health Facilities across the state in order to identify and enroll the children in either CHIP or Medicaid. On-going communication, technical assistance, and program information are provided to the coastal Catholic Charities Refugee Center that provides services to the largest Asian population in the State.

Teens will be reached through the Mississippi Division of Medicaid’s outreach partners such as Jackson Hinds Community Health Center and Children Defense Fund who go into schools to conduct outreach for eligibility. The State will also rely on the MSDH clinics to help identify and enroll teens through family planning and other health outreach programs. The State has also identified public events, school, church, and community teen activities that reach teens.

The State works closely with the Mississippi School for the Deaf and the Mississippi School for the Blind to identify and enroll visually and hearing impaired children and also rely on their staff as resources for developing print and visual material for hearing impaired and audio material for vision impaired children and their families to learn about CHIP. The State also has language assistance available to help with outreach and enrollment for hearing impaired children and limited English speaking population.

The State has targeted two areas of limited English proficiency: Spanish speaking families in the Southern part of the state and Vietnamese speaking families throughout the state. The State has subscribed to a language line service to help with on-site screening and enrollment processes. The Mississippi Division of Medicaid’s website is available in multiple languages.

The State works closely with children’s advocacy groups to define and find solutions to various barriers to enrollment in health programs for children, including Medicaid and CHIP.

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))

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

6.1.1.1.

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

6.1.1.2.

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

6.1.1.3.

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

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

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 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 State expenditures for existing comprehensive state-based coverage.

6.1.4. Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR § 457.450)

6.1.4.1.

Coverage the same as Medicaid State plan

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver

6.1.4.3.

Coverage that either includes the full EPSDT benefit or that the State has extended to the entire Medicaid population

6.1.4.4. Coverage that includes benchmark coverage plus additional coverage

6.1.4.5.

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

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)

6.1.4.7.

Other (Describe) Medicaid “like” excluding non-emergency transportation (NET), EPSDT, Mississippi Youth Programs Around the Clock (MYPAC) and Community Support Programs (CSP).

The benefit period is one (1) calendar year commencing January 1.

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

Must be pre-certified as medically necessary and includes the following:

(1) Hospital room and board (including dietary and general nursing services). (2) Use of operating or treatment rooms. (3) Anesthetics and their administration. (4) Intravenous injections and solutions. (5) Physical therapy. (6) Radiation therapy. (7) Oxygen services and inhalation therapy (8) Diagnostic services, such as x-rays, clinical laboratory examination, electrocardiograms, and electroencephalograms. (9) Drugs and medicines, sera, biological and pharmaceutical preparations used during hospitalization which are listed in the hospital's formulary at the time of hospitalization, including charges for "take home" drugs. (10) Dressings and Supplies, sterile trays, casts, and orthopedic splints. (11) Blood transfusions, including the cost of whole blood, blood plasma and expanders, processing charges, administrative charges, equipment and Supplies. (12) Psychological testing when ordered by the physician and performed by a full-time employee of the hospital subject to limitations. (13) Intensive, Coronary, and Burn Care Unit services. (14) Occupational therapy. (15) Speech therapy.

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

See Physician Services and Surgical Services.

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

Include the following:

(1) In-hospital medical care. (2) Medical care in the physician's office, enrollee’s home, or elsewhere. (3) Surgery.

(4) Dental care, treatment, dental surgery, and dental appliances made necessary by accidental bodily injury to sound and natural teeth (which are free from effects of impairment or disease) effected solely through external means occurring while the enrolled child is covered under the program. Injury to teeth as a result of chewing or biting is not considered an Accidental Injury. Covered medical expense must be incurred as a direct result of an accidental injury to natural teeth and medical treatment must begin within ten (10) days of the accidental injury. (5) Administration of anesthesia and physician administered drugs. (6) Diagnostic services, such as clinical laboratory examinations, x-ray examinations, electrocardiograms, electroencephalograms, and basal metabolism tests. (7) Radiation therapy. (8) Consultations. (9) Psychiatric and psychological service for mental, behavioral and neurodevelopmental disorders, . (10) Physicians assisting in surgery, where appropriate. (11) Emergency care or surgical services rendered in a practitioner’s office including but not limited to surgical and medical supplies, dressings, casts, anesthetic, tetanus, serum, and x-rays. (12) Well child assessments, including vision screening, laboratory tests and hearing screening, according to recommendations A and/or B of the U.S. Preventive Service Task Force. (13) Routine immunizations (according to Advisory Committee on Immunization Practices (ACIP) guidelines)-Vaccine is purchased and distributed through MSDH. The CCO will reimburse providers for the administration of the vaccine. (14) Telehealth services.

Exclusions and limitations include: the CCOs may require prior authorization for physician prescriptions and/or order for outpatient services.

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

Certain surgeries must be pre-certified as medically necessary.

Benefits are provided for the following covered medical expenses furnished to the enrollee by an Ambulatory Surgical Center (ASC):

(1) Services consisting of routine pre-operative laboratory procedures directly related to the surgical procedure. (2) Pre-operative preparation. (3) Use of facility (operating rooms, recovery rooms, and all surgical equipment). (4) Anesthesia, drugs and surgical Supplies.

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

Covered as medical services.

6.2.6. Prescription drugs (Section 2110(a)(6)) Prior authorization is required for selected drugs. A Universal Preferred Drugs List (PDL) will be implemented with provisions for medically necessary exceptions.

The following drugs and certain durable medical equipment (DME) and medical supplies, if medically necessary, U.S. Food and Drug Administration (FDA) approved, non- experimental drugs prescribed by a licensed practitioner, and prescribed for the medical treatment of illness and/or injuries, are covered:

(1) Legend drugs. (2) Compounded medication of which at least one ingredient is a legend drug. (3) Disposable diabetic supplies, including, but not limited to, insulin needles/syringes, blood/urine glucose/acetone testing agents. (4) Insulin. (5) Fluoride supplements.

The following are excluded:

(1) Anabolic steroids. (2) Drugs when used for weight loss. (3) Drugs when used to promote fertility. (4) Over-the-counter (OTC) items except those specifically listed by the Division of Medicaid, updated annually and located on the Division of Medicaid’s website at https://medicaid.ms.gov/providers/ pharmacy/pharmacy-resources/. (5) Drugs used for cosmetic purposes or hair growth, including, but not limited to anti-wrinkle agents, drugs used to treat alopecia, and pigmenting/depigmenting agents. (6) Drugs used for off-label indications which are not found in official compendia or generally accepted in peer reviewed literature. (7) Drugs that are investigational or approved drugs used for investigational purposes. (8) Refills in excess of the number specified by the practitioner or any refills dispensed more than one (1) year after the date of practitioner’s original prescription.

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

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

Certain diagnostic tests must be pre-certified.

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

Exclusions include: For services and supplies related to infertility treatments, artificial insemination, intrauterine insemination and in vitro fertilization regardless of any claim to be medically necessary.

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

(1) Benefits for Covered Medical Expenses are paid for medically necessary inpatient psychiatric treatment of an enrollee. (2) Certification of medical necessity by the UM/QIO or designee is required for

admissions to a hospital.

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)

Benefits for Covered Medical Expenses for treatment of mental, behavioral and neurodevelopmental disorders on an outpatient basis.

State-operated mental hospitals do not offer community-based outpatient services.

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))

Rental of Durable Medical Equipment is covered for temporary therapeutic use; provided, however, when prior authorized by the UM/QIO or designee, the purchase price of such equipment may be allowed. To be Durable Medical Equipment, an item must be (1) made to withstand repeated use; (2) primarily used to serve a medical purpose; (3) generally not useful to a person in the absence of illness, injury or disease; and (4) appropriate for use in the enrollee’s home.

Prosthetic or Orthotic Devices necessary for the alleviation or correction of conditions arising from accidental injury, illness, or congenital abnormalities are covered services. Benefits are available for the initial placement, fitting, and purchase of Prosthetic or Orthotic devices that require a prescription by a physician and for the repair or replacement when medically necessary. Shoes are not covered except for the following: (1) a surgical boot which is part of an upright brace, (2) one pair of mismatched shoes annually in instances where a foot size disparity is greater than two sizes, and (3) a custom fabricated shoe in the case of a significant foot deformity.

Eyeglasses (limited to one (1) per year) and hearing aids (limited to one (1) every three (3) years) are covered services.

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

Supplies provided under the Plan, which are medically necessary disposable items, primarily serving a medical purpose, having therapeutic or diagnostic characteristics essential in enabling an enrollee to effectively carry out a practitioner’s prescribed treatment for illness, injury, or disease, .

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

Services and supplies required for the administration of Home Infusion Therapy regimen must be (1) medically necessary for the treatment of the disease; (2) ordered by a practitioner; (3) as determined by the UM/QIO or designee capable of safe administration in the home; (4) provided by a licensed Home Infusion Therapy provider coordinated and pre-certified by the UM/QIO or designee; (5) ordinarily in lieu of inpatient hospital therapy; and (6) more cost effective than inpatient therapy.

Benefits for home health nursing services must be approved by the UM/QIO or designee in lieu of hospitalization. Benefits for nursing services are limited to ten thousand dollars and zero cents ($10,000.00) annually.

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

Benefits include nursing services of an actively practicing Registered Nurse (RN) or Licensed Practical Nurse (LPN) when ordered and supervised by a practitioner and when the services rendered require the technical skills of an RN or LPN.

Benefits are provided for covered medical expense when performed by a nurse practitioner practicing within the scope of his or her license at the time and place service is rendered.

Benefits for private duty nursing services are provided for an illness or injury that the Insurer’s Utilization Review Program determines to be of such a nature and complexity that the skilled nursing services could not be provided by the hospital's nursing staff. A shift of eight (8) continuous hours or more is required for private duty nursing services. Benefits are also provided for nursing services in the home for illness or injury that the Insurer’s Utilization Review Program determines to require the skills of an RN or LPN. Benefits for nursing services provided in an enrollee’s home must be approved by the UM/QIO or designee in lieu of hospitalization. Benefits for nursing services are limited to ten thousand dollars and zero cents ($10,000.00) annually. (This limit does not apply to nurse practitioner services.) No nursing benefits are provided for:

(1) Services of a nurse who ordinarily lives in the child’s home or is a member of the child’s family; (2) Services of an aide, orderly or sitter; or (3) Nursing services provided in a long-term care facility or inpatient hospital.

Benefits are provided for confinement in a skilled nursing facility for up to sixty (60) days per benefit period, January 1 to December, 31, subject to utilization management requirements.

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)

Benefits are allowed for elective abortion only when documented to be medically necessary within the limits of federal and state law..

6.2.17. 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)

Covered dental services are limited to two thousand dollars and zero cents ($2,000.00) each calendar year (CY).

(1) Benefits are provided for preventive and diagnostic dental care as recommended by the American Academy of Pediatric Dentistry (AAPD), as indicated below:

a. Bitewing X-rays - as needed, but no more frequently than once every six (6)

months; b. Complete Mouth X-ray and Panoramic X-ray - as needed, but no more frequently than once every twenty-four (24) months; c. Prophylaxis - one every six (6) months; must be separated by six (6) full months; d. Fluoride Treatment - limited to one each six (6) month period; e. Space Maintainers - limited to permanent teeth through age 15 years; and f. Sealants - covered up to age 14 years, every thirty-six (36) months.

(2) Benefits are provided for restorative, endodontic, periodontic, and surgical dental services, as indicated below:

a. Amalgam, Silicate, Sedative and Composite Resin Fillings including the replacement of an existing restoration; b. Stainless steel crowns to posterior and anterior teeth; c. Porcelain crowns to anterior teeth only; d. Simple extraction; e. Extraction of an impacted tooth; f. Pulpotomy, pulpectomy, and root canal; and g. Gingivectomy, gingivoplasty and gingival curettage.

Other Dental Services (The calendar year maximum does not apply to these services.)

(1) Benefits are provided for dental care, treatment, dental surgery, and dental appliances made necessary by accidental bodily injury to sound and natural teeth (which are free from effects of impairment or disease) effected solely through external means occurring while the enrolled child is covered under the Program. Injury to teeth as a result of chewing or biting is not considered an accidental injury. (2) Benefits are provided for anesthesia and for associated facility charges when the mental or physical condition of the enrolled child requires dental treatment to be rendered under physician-supervised general anesthesia in a hospital setting, surgical center or dental office. These services must be pre-certified. (3) No benefits will be provided for orthodontics, dentures, occlusion reconstruction, or for inlays unless such services are provided pursuant to an accidental injury as described above or when such services are recommended by a physician or dentist for the treatment of severe craniofacial anomalies or full cusp Class III malocclusions. Diagnosis and surgical treatment for temporomandibular joint (TMJ) disorder or syndrome and craniomandibular disorder, whether such treatment is rendered by a practitioner or dentist, is subject to a lifetime maximum benefit of five thousand dollars and zero cents ($5,000.00) per member. This lifetime maximum will apply regardless of whether the temporomandibular/craniomandibular joint disorder was caused by an accidental injury or was congenital in nature.

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

Benefits for covered medical expenses are provided for the treatment of substance use disorder , whether for alcohol abuse, drug abuse, or a combination of alcohol and drug abuse, as follows:

(1) Benefits for covered medical expenses are provided for medically necessary inpatient

stabilization and residential substance use disorder treatment. (2) Certification of medical necessity by the UM/QIO or designee is required for admissions to a hospital or residential treatment center. (3) Benefits for substance use disorder do not include services for treatment of mental, behavioral and neurodevelopmental disorders.

6.2.19. Outpatient substance use disorder (SUD) treatment services (Section 2110(a)(19))

(1) Benefits are provided for covered medical expenses for medically necessary outpatient SUD treatment services in a hospital, a primary residential substance abuse and rehabilitation center, or community mental health center or private community mental health center. (2) Benefits are provided for covered medical expenses for substance use disorder treatment while not confined as a hospital inpatient. (3) Benefits for substance use disorder do not include services for treatment of mental, behavioral and neurodevelopmental disorders.

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

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

Care coordination is available to members through the CCOs.

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

Benefits are provided for physical therapy services specified in a plan of treatment prescribed by the enrollee’s practitioner and provided by a licensed physical therapist. Not covered for maintenance physical therapy.

Benefits are provided for medically necessary occupational therapy services prescribed by the enrollee’s practitioner and specified in a treatment plan. Occupational therapy services must be provided by a licensed occupational therapist. Not covered for maintenance occupational therapy.

Benefits are provided for medically necessary speech therapy services prescribed by the enrollee’s practitioner and specified in a treatment plan. Speech therapy is not covered for maintenance speech or articulation disorders.

Benefits are provided for an annual hearing examination, if indicated by the results of a hearing screening.

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

Benefits are provided for inpatient and home hospice services, subject to utilization management requirements. Benefits for hospice services are limited to an overall lifetime maximum of fifteen thousand dollars and zero cents ($15,000.00).

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

Benefits are provided for general anesthesia service when requested by the attending physician and performed by an anesthesiologist or a certified registered nurse anesthetist practicing within the scope of his or her license at the time and place service is rendered.

Transplant Benefits:

(1) Any human solid organ or bone marrow/stem cell transplant is covered, provided the following applies:

(i) The enrollee or provider obtains prior approval from the Insurer’s Utilization Management Program; and (ii) The condition is life-threatening; and (iii) Such transplant for that condition is the subject of an ongoing phase III clinical trial; and (iv) Such transplant for that condition follows a written protocol that has been reviewed and approved by an institutional review board, federal agency or other such organization recognized by medical specialists who have appropriate expertise; and (v) The enrollee is a suitable candidate for the transplant under the medical protocols used by the Insurer’s Utilization Management Program.

(2) In addition to regular benefits, benefits are provided for surgical, storage, and transportation expenses incurred and directly related to the donation of an organ or tissue used in a covered organ transplant procedure. (3) Benefits are provided for transportation costs of recipient and two other individuals to and from the site of the transplant surgery and reasonable and necessary expenses for meals and lodging of two individuals at the site of transplant surgery. Reasonable and necessary expenses for transportation, meals, and lodging of two other individuals are provided. Only those expenses which are incurred at the time of the transplant surgery are eligible for reimbursement. Travel expenses incurred as a result of pre- operative and post-operative services are not eligible for reimbursement. Only actual travel expenses supported by receipts are reimbursed. In any event, the total benefits for transportation, meals, and lodging are limited to ten thousand dollars and zero cents ($10,000.00). (4) If a covered solid organ or tissue transplant is provided from a living donor to a human transplant recipient: (i) The following expenses are covered: 1) A search for matching tissue, bone marrow or organ 2) Donor's transportation 3) Charges for removal, withdrawal and preservation, and 4) Donor's hospitalization. (ii) When only the recipient is enrolled in the Program, the donor is entitled to donor coverage benefits. The donor benefits are limited to only those not available to the donor from any other source. This includes, but is not limited to, other insurance coverage or any government program. Benefits provided to the donor will be paid under the recipient’s contract. (iii) When both the recipient and the donor are enrolled in the Program. (iv) When only the donor is a CHIP participant, the donor is not entitled to donor coverage benefits. No benefits are provided to the non-member transplant

recipient. (v) If any organ or tissue is sold rather than donated to the enrollee, no benefits are payable for the purchase price of such organ or tissue;

Manipulative therapy is a covered medical expense but benefits shall not exceed two thousand dollars and zero cents ($2,000.00) annually.

Benefits are provided for medically necessary services and supplies required for the treatment of injury or disease of the eye which fall within the legal scope of practice of a licensed optometrist. Benefits are provided for annual routine eye examinations, eyeglasses, and the fitting of eyeglasses.

Benefits are provided for diabetes self-management training and education, including medical nutrition therapy, for the treatment of diabetes, subject to a limitation of two hundred fifty dollars and zero cents ($250.00) per benefit period, January 1 to December 31.

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

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

Professional ambulance services to the nearest hospital, which is equipped to handle the enrollee’s condition in connection with covered hospital inpatient, care; or when related to and within seventy-two (72) hours after accidental bodily injury or medical emergency whether or not inpatient care is required.

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))

Limitations and Exclusions:

a. For convalescent, custodial, or domiciliary care or rest cures, including room and board, with or without routine nursing care, training in personal hygiene and other forms of self-care or supervisory care by a physician for an enrollee who is mentally or physically disabled as a result of retarded development or body infirmity, or who is not under specific medical, surgical or psychiatric treatment to reduce his disability to the extent necessary to enable him to live outside an institution providing care; neither shall benefits be provided if the enrollee was admitted to a hospital for his or her own convenience or the convenience of his or her physician, or that the care or treatment provided did not relate to the condition for which the enrolled child was hospitalized, or that the hospital stay was excessive for the nature of the injury or illness, it being the intent to provide benefits only for the services required in relation to the condition for which the enrolled child was hospitalized and then only during such time as such services are medically necessary. b. For cosmetic purposes, except for correction of defects incurred by the enrollee while covered under the Program through traumatic injuries or disease requiring surgery. c. For sex therapy or marriage counseling.

d. For custodial care, including sitters and companions. e. For equipment that has a non-therapeutic use (such as humidifiers, air conditioners or filters, whirlpools, wigs, vacuum cleaners, fitness supplies, etc.). f. For procedures, which are Experimental/Investigative in nature. g. For palliative or cosmetic foot care including flat foot conditions, supportive devices for the foot, the treatment for subluxations of the foot, care of corns, bunions (except capsular or bone surgery), calluses, toenails, fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet. h. For services and supplies related to infertility, artificial insemination, intrauterine insemination and in vitro fertilization regardless of any claim to be medically necessary. i. For services which the UM/QIO or designee determines are not medically necessary for treatment of injury or illness. j. For services provided under any federal, state, or governmental plan or law including but not limited to Medicare except when so required by federal law. k. For nursing or personal care facility services i.e., extended care facility, nursing home, or personal care home, except as specifically described elsewhere. l. For treatment or care for obesity or weight control including diet treatment, gastric or intestinal bypass or stapling, or related procedures regardless of any claim of medical necessity or degree of obesity. m. For inpatient rehabilitative services consisting of the combined use of medical, social, educational or vocational services, or any such services designed to enable enrollees disabled by disease or injury to achieve functional ability, except for acute short-term care in a hospital or rehabilitation hospital as approved by the UM/QIO or designee. n. For outpatient rehabilitative services consisting of pulmonary rehabilitation, or the combined use of medical, social, educational or vocational services, or any such services designed to enable enrollees disabled by disease or injury to achieve functional ability, except for physical, occupational, or speech therapy services specified in a plan of treatment prescribed by the enrollee’s physician and provided by a licensed therapist. o. For care rendered by a provider, (physician or other provider) who is related to the covered enrollee by blood or marriage or who regularly resides in the enrolled child’s household. p. For services rendered by a provider not practicing within the scope of his license at the time and place service is rendered. q. For treatment related to sex transformations regardless of claim of medical necessity or for sexual function, sexual dysfunction or inadequacies not related to organic disease. r. For reversal of sterilization regardless of claim of medical necessity. s. For elective abortion unless documented to be medically necessary within the limits of state and federal law. t. For charges for telephone consultations, failure to keep a scheduled visit, completion of a claim form, or to obtain medical records or information required to adjudicate a claim. u. For travel, whether or not recommended by a physician, except as provided for under Transplant Benefits. v. Because of diseases contracted or injuries sustained as a result of war, declared or undeclared, or any act of war.

w. For treatment of any injury arising out of or in the course of employment or any sickness entitling the enrollee to benefits under any Workers' Compensation or Employer Liability Law. x. For any injury growing out of a wrongful act or omission of another party for which injury that party or some other party makes settlement or is legally responsible; provided, however, that if the enrollee is unable to recover from the responsible party, benefits shall be provided. y. For refractive surgery such as radial keratotomy and other procedures to alter the refractive properties of the cornea. z. Sub-acute care and swing beds.

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

Link to Covered Dental Codes

6.2.1.1-DC Periodicity Schedule. The State has adopted the following periodicity schedule:

State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached)

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

Current Dental Terminology, © 2018 American Dental Association. All rights reserved.

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) Page - 11 – State Health Official

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 2103(a)(5). Please update Sections 1.1-DS, 4.1-DS, 4.2-DS, and 9.10 when electing this option.

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

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

6.3.2. The State contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.6.2. (formerly 6.4.2) of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Describe: Previously 8.6

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

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

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the

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

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))

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))

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?

Yes

No

6.4.3.1-PA Qualified Employer-Sponsored Coverage and Premium Assistance Subsidy

6.4.3.1.1-PA Provide an assurance that the qualified employer-sponsored insurance meets the definition of qualified employer-sponsored coverage as defined in Section 2105(c)(10)(B), and that the premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(C).

6.4.3.1.2-PA Describe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee’s employer.

6.4.3.2-PA: Supplemental Coverage for Benefits and Cost Sharing Protections Provided under the Child Health Plan.

6.4.3.2.1-PA If the State is providing premium assistance for qualified employer- sponsored coverage, as defined in Section 2105(c)(10)(E)(i), provide an assurance that the State is providing for each targeted low-income child enrolled in such coverage, supplemental coverage consisting of all items or services that are not covered or are only partially covered, under the qualified employer-sponsored coverage consistent with 2103(a) and cost sharing protections consistent with Section 2103(e).

6.4.3.2.2-PA Describe whether these benefits are being provided through the employer or by the State providing wraparound benefits.

6.4.3.2.3-PA If the State is providing premium assistance for benchmark or benchmark-equivalent coverage, the State ensures that such group health plans or health insurance coverage offered through an employer will be certified by an actuary as coverage that is equivalent to a benchmark benefit package described in Section 2103(b) or benchmark equivalent coverage that meets the requirements of Section 2103(a)(2).

6.4.3.3-PA: Application of Waiting Period Imposed Under State Plan: States are required to apply the same waiting period to premium assistance as is applied to direct coverage for children under their CHIP State plan, as specified in Section 2105(c)(10)(F).

6.4.3.3.1-PA Provide an assurance that the waiting period for children in premium assistance is the same as for those children in direct coverage (if State has a waiting period in place for children in direct CHIP coverage).

6.4.3.4-PA: Opt-Out and Outreach, Education, and Enrollment Assistance

6.4.3.4.1-PA Describe the State’s process for ensuring parents are permitted to disenroll their child from qualified employer-sponsored coverage and to enroll in CHIP effective on the first day of any month for which the child is eligible for such assistance and in a manner that ensures continuity of coverage for the child (Section 2105(c)(10)(G)).

6.4.3.4.2-PA Describe the State’s outreach, education, and enrollment efforts related to premium assistance programs, as required under Section 2102(c)(3). How does the State inform families of the availability of premium assistance, and assist them in obtaining such subsidies? What are the specific significant resources the State intends to apply to educate employers about the availability of premium assistance subsidies under the State child health plan? (Section 2102(c))

6.4.3.5-PA: Purchasing Pool- A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool (Section 2105(c)(10)(I)). Does the State provide this option?

Yes

No

6.6.3.5.1-PA Describe the plan to establish an employer-family premium assistance purchasing pool.

6.6.3.5.2-PA Provide an assurance that employers who are eligible to participate: 1) have less than 250 employees; 2) have at least one employee who is a pregnant woman eligible for CHIP or a member of a family that has at least one child eligible under the State’s CHIP plan.

6.6.3.5.3-PA Provide an assurance that the State will not claim for any administrative expenditures attributable to the establishment or operation of such a pool except to the extent such payment would otherwise be permitted under this title.

6.4.3.6-PA Notice of Availability of Premium Assistance- Describe the procedures that assure that if a State provides premium assistance subsidies under this Section, it must: 1) provide as part of the application and enrollment process, information describing the availability of premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to ensure that parents are fully informed of the choices for child health assistance or through the receipt of premium assistance subsidies (Section 2105(c)(10)(K)).

6.4.3.6.1-PA Provide an assurance that the State includes information about premium assistance on the CHIP application or enrollment form.

Section 9. Strategic Objectives and Performance Goals and Plan Administration

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)) (42 CFR § 457.710(b))

1. The infrastructure of the Mississippi Medicaid agency will continue to accommodate all critical facets of outreach and eligibility determination for the Title XXI program. 2. Low income children who were previously without health insurance coverage will have health insurance coverage through Mississippi's Title XXI program. 3. Children enrolled in CHIP will have adequate access to primary care, inpatient care, and pharmacy services. 4. Children enrolled in CHIP will receive appropriate preventive and primary care services. 5. Families of CHIP enrollees will be surveyed annually regarding their satisfaction with the services provided under the Program.

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

Performance Goal for Objective 1:

The Mississippi Division of Medicaid will continue to support data systems modification, eligibility determinations, enrollment, participation information, health service utilization, billing, health status, provider information, personnel- (i.e., eligibility workers, administrative and support staff), staff training, publications and documents for the CHIP program.

Performance Goals for Objective 2:

Continue to screen for CHIP eligibility for those children whose family income is between 133% and 209% FPL

Performance Goal for Objective 3:

At least 85% of children enrolled in CHIP will have access to a primary care physician within 15 miles in urban/suburban areas and 30 miles in rural areas.

At least 85% of children enrolled in CHIP will have access to a hospital within 30 miles in urban/suburban areas and 60 miles in rural areas.

At least 85% of children enrolled in CHIP will have access to a pharmacy within 30 miles in urban/suburban areas and 60 miles in rural areas.

Performance Goal for Objective 4:

At least 85% of children 2 years of age enrolled in CHIP will receive all immunizations as recommended by ACIP.

At least 85% of CHIP enrollees between 2 to 6 years of age will receive at least one (1) preventive or primary care visit during the year.

At least 85% of children in CHIP will receive required screenings.

Performance Goals for Objective 5:

At least 70% of families responding to the member satisfaction survey will express satisfaction with customer service and provider access.

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)) (42 CFR § 457.710(d))

The CCOs will provide encounter data to the State’s fiscal agent so the analytics vendor can produce required reports to the Mississippi Division of Medicaid for further analysis.

The fiscal agent and DOM’s contracted analytics engine will be able to measure and track enrollment data and the following Healthcare Effectiveness Data and Information Set (HEDIS) performance measures for the targeted CHIP population:

(a) Well child visits in the 3rd, 4th, 5th, and 6th years of life; (b) Use of appropriate medications for children with asthma; (c) Children’s access to primary care practitioners; (d) Drug utilization; (e) Inpatient utilization – general hospital/acute care; (f) Mental health utilization; and (g) Annual dental visits.

Objective 1:

Eligibility and enrollment are evaluated on an ongoing basis. Reports from Envision, the Mississippi Division of Medicaid’s patient information management system, on the number of applications approved, both pending and denied are reviewed on a monthly basis and appropriate interventions are implemented as indicated. The activities of each Medicaid specialist are monitored to determine maximum worker caseload.

Objective 2:

Enrollment is measured by the Mississippi Division of Medicaid, which provides eligibility determination services for both Medicaid and CHIP.

Objective 3:

Access is measured by the CCOs using GeoAccess software applied to the CHIP enrollment file and network provider file.

Utilization of preventive and primary care services is measured by the CCOs. The CCOs will provide encounter data to the State’s fiscal agent so that the analytics vendor can produce required reports and provide the data to the Mississippi Division of Medicaid for further analysis.

Objective 4:

Satisfaction is measured by the CCOs through an annual member satisfaction survey.

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

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

9.3.2. The reduction in the percentage of uninsured children.

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

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

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

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

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

9.3.7.1.

Immunizations 9.3.7.2.

Well childcare 9.3.7.3.

Adolescent well visits 9.3.7.4.

Satisfaction with care 9.3.7.5.

Mental health 9.3.7.6.

Dental care 9.3.7.7.

Other, list: Access to primary care

9.3.8. Performance measures for special targeted populations.

9.4.

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

9.5.

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

The Medicaid agency uses the same staff to evaluate and assess CHIP quality of care.

There are reliable state-wide or comparable sub-group measures of morbidity of the Medicaid population to measure the effectiveness of the coverage of individuals enrolled in this proposed expansion.

In CHIP, the CCOs submit encounter data to the fiscal agent. The system generates standard reports and enables ad hoc reporting.

9.6.

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

9.7.

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

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

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

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

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

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

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

The process of design and implementation of CHIP was open to allow input and participation from various interested and affected parties. Initial decisions were reached during the 1998 Legislative session in which Legislators received input from recipients, providers, advocates, the business community, medical care industry, and religious and political leaders. Phase I of CHIP was set forth in statute, together with a Commission to design Phase II. Phase I CHIP was publicized in the routine manner through the State of Mississippi's Administrative Procedures Act. The CHIP Commission was appointed, according to state statute, to develop proposals regarding benefits, funding, and eligibility of children. The CHIP Commission meetings were open to the public, as were the meetings of the three subcommittees established to develop recommendations with respect to structure, benefits and eligibility and outreach. Public hearings were held in four locations across the state, and an advance notice of these meetings was published in both the newspaper with statewide distribution as well as local papers. In addition, the Mississippi Division of Medicaid authored news releases, editorials, and public service announcements on educational television and public radio. To date, information about and application for the State's CHIP is available on the Internet at the Mississippi Division of Medicaid's web page http://www.medicaid.ms.gov. The Mississippi Division of Medicaid has established statewide coalitions not only to assist with dissemination of Mississippi Health Benefit (MHB) applications and materials but also to relay families’ experiences and concerns to the Mississippi Division of Medicaid. Finally, the Mississippi Division of Medicaid has

maintained an extensive mailing list, and all materials and updates developed are distributed ongoing to all included therein.

9.9.1 Describe the process used by the State to ensure interaction with Indian Tribes and organizations in the State on the development and implementation of the procedures required in 42 CFR § 457.125. States should provide notice and consultation with Tribes on proposed pregnant women expansions. (Section 2107(c)) (42 CFR § 457.120(c))

Refer to Section 2.3-TC.

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).9.9.2 Describe the State’s interaction, consultation, and coordination with any Indian tribes and organizations in the State regarding implementation of the Express Lane eligibility option.

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. 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 use disorder treatment services and residential substance use disorder treatment services. 19. Outpatient substance use disorder 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. 24. Premiums for private health care insurance coverage. 25. Medical transportation. 26. 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. 27. 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—

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 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.

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Mississippi CHIP Plan Covered Services $2,000 Annual Maximum - No Deductible PROCEDURES NOT LISTED ARE NOT A BENEFIT OF THIS PLAN - IF YOU HAVE A QUESTION REGARDING PLAN BENEFITS, PLEASE CONTACT PROVIDER SERVICES FOR ASSISTANCE. The following contains Code on Dental Procedures and Nomenclature (CDT Code), copyright © 2019 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. U.S. Government Rights. This product includes CDT, which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Dental Association, 211 East Chicago Avenue, Chicago, Illinois, 60611. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.” The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. CDT Code Description of Procedure Covered Benefit Min Age Max Age Limitation Auth Required D0120 PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT YES 0 19 1 EVERY 6 MONTHS NO D0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED YES 0 19 N/A NO D0145 ORAL EVALUATION FOR A PATIENT UNDER THREE YEARS OF AGE AND COUNSELING WITH PRIMARY CAREGIVER YES 0 2 1 EVERY 6 MONTHS NO D0150 COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT YES 0 19 1 EVERY 36 MONTHS NO D0210 INTRAORAL-COMPLETE SERIES OF RADIOGRAPHIC IMAGES YES 0 19 1 EVERY 24 MONTHS NO D0220 INTRAORAL-PERIAPICAL FIRST RADIOGRAPHIC IMAGE YES 0 19 N/A NO D0230 INTRAORAL-PERIAPICAL EACH ADDITIONAL RADIOGRAPHIC IMAGE YES 0 19 N/A NO D0270 BITEWING-SINGLE RADIOGRAPHIC IMAGE YES 0 19 1 EVERY 6 MONTHS NO D0272 BITEWINGS-TWO RADIOGRAPHIC IMAGES YES 0 19 1 EVERY 6 MONTHS NO D0273 BITEWINGS-THREE RADIOGRAPHIC IMAGES YES 0 19 1 EVERY 6 MONTHS NO D0274 BITEWINGS-FOUR RADIOGRAPHIC IMAGES YES 0 19 1 EVERY 6 MONTHS NO D0321 OTHER TEMPOROMANDIBULAR JOINT RADIOGRAPHIC IMAGES BY REPORT ³ SEE TMJ DISORDER BENEFIT 0 19 ³ SEE TMJ DISORDER BENEFIT YES D0330 PANORAMIC RADIOGRAPHIC IMAGE YES 0 19 1 EVERY 24 MONTHS NO D0340 2D CELPHALOMETRIC RADIOGRAPHIC IMAGE - ACQUISITION, MEASUREMENT AND ANALYSIS YES 0 19 1 EVERY 12 MONTHS NO D0350 2D ORAL/FACIAL PHOTOGRAPHIC IMAGE OBTAINED INTRA-ORALLY OR EXTRA-ORALLY YES 0 19 1 EVERY 12 MONTHS NO D0411 HbA1C IN-OFFICE POINT OF SERVICE TESTING YES 0 19 BY REPORT NO D0470 DIAGNOSTIC CASTS YES 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT NO

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CDT Code Description of Procedure Covered Benefit Min Age Max Age Limitation Auth Required D0999 UNSPECIFIED DIAGNOSTIC PROCEDURE, BY REPORT YES 0 19 BY REPORT YES D1120 PROPHYLAXIS - CHILD YES 0 19 1 EVERY 6 MONTHS NO D1206 TOPICAL APPLICATION OF FLUORIDE VARNISH YES 0 19 1 EVERY 6 MONTHS NO D1208 TOPICAL APPLICATION OF FLUORIDE – EXCLUDING VARNISH YES 0 19 1 EVERY 6 MONTHS NO D1351 SEALANT - PER TOOTH YES 0 19 1 EVERY 5 YRS MOLARS ONLY NO D1510 SPACE MAINTAINER - FIXED-UNILATERAL YES 0 19 PERMANENT TEETH ONLY NO D1516 SPACE MAINTAINER - FIXED - BILATERAL, MAXILLARY YES 0 19 PERMANENT TEETH ONLY NO D1517 SPACE MAINTAINER - FIXED - BILATERAL, MANDIBULAR YES 0 19 PERMANENT TEETH ONLY NO D1520 SPACE MAINTAINER - REMOVABLE- UNILATERAL YES 0 19 PERMANENT TEETH ONLY NO D1526 SPACE MAINTAINER - FIXED - BILATERAL, MAXILLARY YES 0 19 PERMANENT TEETH ONLY NO D1527 SPACE MAINTAINER - FIXED - BILATERAL, MANDIBULAR YES 0 19 PERMANENT TEETH ONLY NO D1550 RE-CEMENT OR RE-BOND SPACE MAINTAINER YES 0 19 N/A NO D1555 REMOVAL OF FIXED SPACER MAINTAINER YES 0 19 N/A NO D2140 AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT YES 0 19 N/A NO D2150 AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT YES 0 19 N/A NO D2160 AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT YES 0 19 N/A NO D2161 AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT YES 0 19 N/A NO D2330 RESIN-BASED COMPOSITE – ONE SURFACE, ANTERIOR YES 0 19 N/A NO D2331 RESIN-BASED COMPOSITE -TWO SURFACES, ANTERIOR YES 0 19 N/A NO D2332 RESIN-BASED COMPOSITE -THREE SURFACES, ANTERIOR YES 0 19 N/A NO D2335 RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR) YES 0 19 N/A NO D2390 RESIN-BASED COMPOSITE CROWN, ANTERIOR YES 0 19 N/A NO D2391 RESIN-BASED COMPOSITE - ONE SURFACE, POSTERIOR YES 0 19 N/A NO D2392 RESIN-BASED COMPOSITE - TWO SURFACES, POSTERIOR YES 0 19 N/A NO D2393 RESIN-BASED COMPOSITE - THREE SURFACES, POSTERIOR YES 0 19 N/A NO D2394 RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR YES 0 19 N/A NO D2750 CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL YES 0 19 1 EVERY 5 YRS ANTERIOR TEETH ONLY YES D2751 CROWN-PROCELAIN FUSED TO PREDOMINANTLY BASE METAL YES 0 19 1 EVERY 5 YRS ANTERIOR TEETH ONLY YES D2752 CROWN-PORCELAIN FUSED TO NOBLE METAL YES 0 19 1 EVERY 5 YRS ANTERIOR TEETH ONLY YES D2930 PREFABRICATED STAINLESS STEEL CROWN - PRIMARY TOOTH YES 0 19 N/A NO D2931 PREFABRICATED STAINLESS STEEL CROWN - PERMANENT TOOTH YES 0 19 N/A NO

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CDT Code Description of Procedure Covered Benefit Min Age Max Age Limitation Auth Required D2933 PREFABRICATED STAINLESS STEEL CROWN WITH RESIN WINDOW YES 0 19 ANTERIOR TEETH ONLY NO D2934 PREFABRICATED ESTHETIC COATED STAINLESS STEEL CROWN - PRIMARY TOOTH YES 0 19 N/A NO D2940 PROTECTIVE RESTORATION YES 0 19 N/A YES D2952 POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATED YES 0 19 N/A YES D2999 UNSPECIFIED RESTORATIVE PROCEDURE, BY REPORT YES 0 19 N/A YES D3220 THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) REMOVAL OF PULP CORONAL TO THE DENTINOCEMENTAL JUNCTION AND APPLICATION OF MEDICAMENT YES 0 19 N/A NO D3222 PARTIAL PULPOTOMY FOR APEXOGENESIS - PERMANENT TOOTH WITH INCOMPLETE ROOT DEVELOPMENT YES 0 19

N/A NO D3310 ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL RESTORATION) YES 0 19 1 PER LIFETIME PER TOOTH NO D3320 ENDODONTIC THERAPY, PREMOLAR BICUSPID TOOTH (EXCLUDING FINAL RESTORATION) YES 0 19 1 PER LIFETIME PER TOOTH NO D3330 ENDODONTIC THERAPY, MOLAR TOOTH (EXCLUDING FINAL RESTORATION) YES 0 19 1 PER LIFETIME PER TOOTH NO D3346 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - ANTERIOR YES 0 19 1 PER LIFETIME PER TOOTH YES D3347 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - PREMOLAR YES 0 19 1 PER LIFETIME PER TOOTH YES D3348 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - MOLAR YES 0 19 1 PER LIFETIME PER TOOTH YES D3999 UNSPECIFIED ENDODONTIC PROCEDURE, BY REPORT YES 0 19 BY REPORT YES D4210 GINGIVECTOMY OR GINGIVOPLASTY-FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT, PERFORMED TO ELIMINATE SUPRABONY POCKETS YES 0 19 1 EVERY 36 MONTHS NO D4211 GINGIVECTOMY OR GINGIVOPLASTY ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT YES 0 19 1 EVERY 36 MONTHS NO D4240 GINGIVAL FLAP PROCEDURE INCLUDING ROOT PLANING - FOUR OR MORE CONTINGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT YES 10 19 1 PROCEDURE PER QUADRANT EVERY 12 MONTHS NO D4241 GINGIVAL FLAP PROCEDURE INCLUDING ROOT PLANING - ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT YES 10 19 1 PROCEDURE PER QUADRANT EVERY 12 MONTHS NO D4260 OSSEOUS SURGERY (INCLUDING ELEVATION OF A FULL THICKNESS FLAP AND CLOSURE)- FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACE PER QUANDRANT YES 0 19 1 PROCEDURE PER LIFETIME PER QUADRANT NO D4261 OSSEOUS SURGERY (INCLUDING ELEVATION OF A FULL THICKNESS FLAP AND CLOSURE)- ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUANDRANT YES 0 19 1 PROCEDURE PER LIFETIME PER QUADRANT NO D4341 PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANT YES 10 19 2 QUADS PER VISIT 4 QUADS PER YEAR NO D4342 PERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH, PER QUADRANT YES 10 19 2 QUADS PER VISIT 4 QUADS PER YEAR NO

Page 4 of 10 November 1, 2019

CDT Code Description of Procedure Covered Benefit Min Age Max Age Limitation Auth Required D5110 COMPLETE DENTURE - MAXILLARY ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT YES D5120 COMPLETE DENTURE - MANDIBULAR ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT YES D5211 MAXILLARY PARTIAL DENTURE - RESIN BASED (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH) ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT YES D5212 MANDIBULAR PARTIAL DENTURE - RESIN BASE (INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS, AND TEETH) ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT YES D5221 IMMEDIATE MAXILLARY PARTIAL DENTURE- RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH) YES 0 19 1 PER 36 MONTHS YES D5222 IMMEDIATE MANDIBULAR PARTIAL DENTURE- RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH) YES 0 19 1 PER 36 MONTHS YES D5955 PALATAL LIFT PROSTHESIS,DEFINITIVE YES 0 19 WHEN MEDICALLY NECESSARY YES D6999 UNSPECIFIED FIXED PROSTHODONTIC PROCEDURE, BY REPORT YES 0 19 BY REPORT YES D7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMO YES 0 19 1 PER LIFETIME PER TOOTH NO D7210 EXTRACTION, ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING OF TOOTH, AND INCLUDING ELEVATION OF MUCOPERISOTEAL FLAP IF INDICATED. YES 0 19 1 PER LIFETIME PER TOOTH NO D7220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUE YES 0 19 1 PER LIFETIME PER TOOTH NO D7230 REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY YES 0 19 1 PER LIFETIME PER TOOTH NO D7240 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY YES 0 19 1 PER LIFETIME PER TOOTH NO D7241 REM.IMP. TOOTH, COMPLETELY BONY, WITH UNUSUAL SURG. COMPLICATIONS YES 0 19 1 PER LIFETIME PER TOOTH NO D7250 REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) YES 0 19 1 PER LIFETIME PER TOOTH NO D7251 CORONECTOMY - INTENTIONAL PARTIAL TOOTH REMOVAL YES 0 19 WHEN MEDICALLY NECESSARY YES D7260 ORAL ANTRAL FISTULA CLOSURE YES 0 19 WHEN MEDICALLY NECESSARY NO D7270 TOOTH REIMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY EVULSED OR DISPLACED TOOTH ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT NO D7272 TOOTH TRANSPLANTATION (INCLUDES RE- IMPLANTATION FROM ONE SITE TO ANOTHER AND SPLINTING AND/OR STABILIZATION) YES 0 19 WHEN MEDICALLY NECESSARY YES D7280 EXPOSURE OF AN UNERUPTED TOOTH YES 0 19 WHEN MEDICALLY NECESSARY YES D7285 INCISIONAL BIOPSY OF ORAL TISSUE- HARD (BONE, TOOTH) YES 0 19 WHEN MEDICALLY NECESSARY NO D7286 INCISIONAL BIOPSY OF ORAL TISSUE - SOFT YES 0 19 WHEN MEDICALLY NECESSARY NO

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CDT Code Description of Procedure Covered Benefit Min Age Max Age Limitation Auth Required D7288 BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION

YES

0

19 WHEN MEDICALLY NECESSARY

YES D7290 SURGICAL REPOSITIONING OF TEETH

YES

0

19 WHEN MEDICALLY NECESSARY

NO D7296 CORTICOTOMY - ONE TO THREE TEETH OR TOOTH SPACES PER QUADRANT

YES

0

19 WHEN MEDICALLY NECESSARY

NO D7297 CORTICOTOMY - FOUR OR MORE TEETH OR TOOTH SPACES PER QUADRANT

YES

0

19 WHEN MEDICALLY NECESSARY

NO D7310 ALVEOLOPLASTY IN CONJUCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH SPACES PER QUADRANT

YES

0

19 WHEN MEDICALLY NECESSARY

NO D7311 ALVEOLOPLASY IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH YES 0 19 WHEN MEDICALLY NECESSARY NO D7320 ALVEOLOPLASTY NOT IN CONJUCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH SPACES PER QUADRANT YES 0 19 WHEN MEDICALLY NECESSARY NO D7321 ALVEOLOPLASY NOT IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH YES 0 19 WHEN MEDICALLY NECESSARY NO D7340 VESTIBULOPLASTY - RIDGE EXTENSION (SECOND EPITHELIALIZATION) YES 0 19 WHEN MEDICALLY NECESSARY NO D7350 VESTIBULOPLASTY - RIDGE EXTENSION (INCLUDING SOFT TISSUE GRAFTS, MUSCLE REATTACHMENT, REVISOIN OF SOFT TISSUE ATTACHMENT AND MANGEMENT OF HYPERTROPHIED AND HYPERPLASTIC TISSUE) YES 0 19 WHEN MEDICALLY NECESSARY NO D7410 EXCISION OF BENIGN LESION UP TO 1.25 CM YES 0 19 WHEN MEDICALLY NECESSARY NO D7411 EXCISION OF BENIGN LESION GREATER THAN 1.25 CM YES 0 19 WHEN MEDICALLY NECESSARY NO D7413 EXCISION OF MALIGNANT LESION UP TO 1.25 CM YES 0 19 WHEN MEDICALLY NECESSARY NO D7414 EXCISION OF MALIGNANT LESION GREATER THAN 1.25 CM YES 0 19 WHEN MEDICALLY NECESSARY NO D7440 EXCISION OF MALIGNANT TUMOR - LESION DIAMETER UP TO 1.25 CM YES 0 19 WHEN MEDICALLY NECESSARY NO D7441 EXCISION OF MALIGNANT TUMOR - LESION DIAMETER OVER 1.25 CM YES 0 19 WHEN MEDICALLY NECESSARY NO D7450 REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR-LESION DIAMETER UP T0 1.25 CM YES 0 19 WHEN MEDICALLY NECESSARY NO D7451 REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR-LESION DIAMETER GREATER THAN 1.25 CM YES 0 19 WHEN MEDICALLY NECESSARY NO D7460 REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR-LESION DIAMETER UP TO 1.25 CM YES 0 19 WHEN MEDICALLY NECESSARY NO D7461 REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR-LESION DIAMETER GREATER THAN 1.25 CM YES 0 19 WHEN MEDICALLY NECESSARY NO D7465 DESTRUCTION OF LESION(S) BY PHYSICAL OR CHEMICAL METHODS, BY REPORT YES 0 19 WHEN MEDICALLY NECESSARY NO

Page 6 of 10 November 1, 2019

CDT Code Description of Procedure Covered Benefit Min Age Max Age Limitation Auth Required D7471 REMOVAL OF LATERAL EXOSTOSIS (MAXILLA OR MANDIBLE) YES

0

19 WHEN MEDICALLY NECESSARY

NO D7490 RADICAL RESECTION OF MAXILLA OR MANDIBLE YES 0 19 WHEN MEDICALLY NECESSARY YES D7510 INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE YES 0 19 WHEN MEDICALLY NECESSARY NO D7520 INCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE YES 0 19 WHEN MEDICALLY NECESSARY NO D7530 REMOVAL OF FOREIGN BODY FROM MUCOSA, SKIN, OR SUBCUTANEOUS ALVEOLAR TISSUE YES 0 19 WHEN MEDICALLY NECESSARY NO D7540 REMOVAL OF REACTION-PRODUCING FOREIGN BODIES – MUSCULOSKELETAL SYSTEM YES 0 19 WHEN MEDICALLY NECESSARY NO D7550 PARTIAL OSTECTOMY/SEQUESTRECTOMY FOR REMOVAL OF NON-VITAL BONE YES 0 19 WHEN MEDICALLY NECESSARY NO D7560 MAXILLARY SINUSOTOMY FOR REMOVAL OF TOOTH FRAGMENT OR FOREIGN BODY YES 0 19 WHEN MEDICALLY NECESSARY NO D7610 MAXILLA - OPEN REDUCTION (TEETH IMMOBILIZED IF PRESENT) YES 0 19 WHEN MEDICALLY NECESSARY NO D7620 MAXILLA - CLOSED REDUCTION (TEETH IMMOBILIZED IF PRESENT) YES 0 19 WHEN MEDICALLY NECESSARY NO D7630 MANDIBLE - OPEN REDUCTION (TEETH IMMOBILIZED IF PRESENT) YES 0 19 WHEN MEDICALLY NECESSARY NO D7640 MANDIBLE - CLOSED REDUCTION (TEETH IMMOBILIZED IF PRESENT) YES 0 19 WHEN MEDICALLY NECESSARY NO D7650 MALAR AND/OR ZYGOMATIC ARCH - OPEN REDUCTION YES 0 19 WHEN MEDICALLY NECESSARY NO D7660 MALAR AND/OR ZYGOMATIC ARCH - CLOSED REDUCTION YES 0 19 WHEN MEDICALLY NECESSARY NO D7670 ALVEOLUS - CLOSED REDUCTION, MAY INCLUDE STABILIZATION OF TEETH YES 0 19 WHEN MEDICALLY NECESSARY NO D7671 ALVEOLUS - OPEN REDUCTION, MAY INCLUDE STABILIZATION OF TEETH YES 0 19 WHEN MEDICALLY NECESSARY NO D7680 FACIAL BONES - COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICAL APPROACHES YES 0 19 WHEN MEDICALLY NECESSARY NO D7710 MAXILLA - OPEN REDUCTION YES 0 19 WHEN MEDICALLY NECESSARY NO D7720 MAXILLA - CLOSED REDUCTION YES 0 19 WHEN MEDICALLY NECESSARY NO D7730 MANDIBLE - OPEN REDUCTION YES 0 19 WHEN MEDICALLY NECESSARY NO D7740 MANDIBLE - CLOSED REDUCTION YES 0 19 WHEN MEDICALLY NECESSARY NO D7750 MALAR AND/OR ZYGOMATIC ARCH - OPEN REDUCTION YES 0 19 WHEN MEDICALLY NECESSARY NO

Page 7 of 10 November 1, 2019

CDT Code Description of Procedure Covered Benefit Min Age Max Age Limitation Auth Required D7760 MALAR AND/OR ZYGOMATIC ARCH - CLOSED REDUCTION YES 0 19 WHEN MEDICALLY NECESSARY NO D7770 ALVEOLUS - OPEN REDUCTION STABILIZATION OF TEETH ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT NO D7780 FACIAL BONES COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE APPROACHES ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT NO D7810 OPEN REDUCTION OF DISLOCATION ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT NO D7820 CLOSED REDUCTION OF DISLOCATION ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT NO D7830 MANIPULATION UNDER ANESTHESIA ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT NO D7840 CONDYLECTOMY ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT NO D7850 SURGICAL DISCECTOMY, WITH/WITHOUT IMPLANT ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT NO D7860 ARTHROTOMY ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT YES D7870 ARTHROCENTESIS ¹ SEE ACCIDENTAL INJURY BENEFIT 0 19 ¹ SEE ACCIDENTAL INJURY BENEFIT NO D7910 SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM YES 0 19 WHEN MEDICALLY NECESSARY NO D7911 COMPLICATED SUTURE-UP TO5CM YES 0 19 WHEN MEDICALLY NECESSARY NO D7912 COMPLICATED SUTURE-GREATER THAN 5CM YES 0 19 WHEN MEDICALLY NECESSARY YES D7920 SKIN GRAFT (IDENTIFY DEFECT COVERED, LOCATION, AND TYPE OF GRAFT) YES 0 19 WHEN MEDICALLY NECESSARY NO D7940 OSTEOPLASTY - FOR ORTHOGNATHIC DEFORMITIES YES 0 19 WHEN MEDICALLY NECESSARY YES D7941 OSTEOTOMY - MANDIBULAR RAMI YES 0 19 WHEN MEDICALLY NECESSARY YES D7943 OSTEOTOMY - MANDIBULAR RAMI WITH BONE GRAFT; INCLUDES OBTAINING THE GRAFT YES 0 19 WHEN MEDICALLY NECESSARY YES D7944 OSTEOTOMY - SEGMENTED OR SUBAPICAL YES 0 19 WHEN MEDICALLY NECESSARY YES