DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

October 19, 2012

David J. Dzielak, Ph.D. Executive Director Division of Medicaid, Office of the Governor 550 High Street, Suite 1000 Jackson, Mississippi 39201

Re: Mississippi State Plan Amendment (SPA), Transmittal # MS 12-002

Dear Dr. Dzielak:

We have reviewed Mississippi State Plan Amendment (SPA) 12-002, which was submitted to the Atlanta Regional Office on July 23, 2012. This SPA was submitted to make changes to Optometrist services available in the Mississippi State Plan. It will add Optometrist services as a covered service allowing Optometrist coverage to all eligible beneficiaries, not just the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) beneficiaries. This correction will conform to current state law and federal regulations and allow Optometric service providers to participate in the Medicaid Electronic Health Record (EHR) incentive program for eligible professionals.

Based on the information provided, we are now ready to approve Mississippi SPA 12-002 as of October 19, 2012. The effective date is July 1, 2012. The signed CMS-179 and the approved plan pages are enclosed. If you have any questions regarding this amendment, please contact Carolyn Brown at (404) 565-7421.

Sincerely,

/s/

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

Enclosures

TN No. 2012-002

Supersedes TN No. 87-9 Approval Date:10-19-12 Effective Date 7/1/12 27 State/ Territory: Mississippi Revision: HCFA-PM-87-5 (BERC) OMB No.: 0938-0193 April 1987 State: Mississippi

Citation 42 CFR 441.30 AT-78-90 3.1 (f) (1) Optometric Services

Optometric services (other than those provided under §435.531 and 436.531) are not now but were previously provided under the plan. Services of the type an optometrist is legally authorized to perform are specifically included in the term “physicians’ services” under this plan and are reimbursed whether furnished by a physician or an optometrist.

☒ Yes.

☐ No. The conditions described in the first sentence apply but the term “physicians’ services” does not specifically include services of the type an optometrist is legally authorized to perform.

☐ Not applicable. The conditions in the first sentence do not apply. 1903 (i) (1) of the Act, P.L. 99-272 ( Section 9507)

(2) Organ Transplant Procedures

Organ transplant procedures are provided.

☐ No.

☒ Yes. Similarly situated individuals are treated alike and any restriction on the facilities that may, or practitioners who may, provide those procedures is consistent with the accessibility of high quality care to individuals eligible for the procedures under this plan. Standards for the coverage of organ transplant procedures are described at Attachment 3.1-E.

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | !. TRANSMITTAL NUMBER: 2. STATE ‘STATE PLAN MATERIAL 2012-002 MS

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE

: ING A FOR: HEALTH CARE FINANCING ADMINISTRATION SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One):

07/01/2012

(NEW STATE PLAN ( AMENDMENT TO BE CONSIDERED AS NEW PLAN —] AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT:

a. FFY $0.00 42 CFR 441.30 b. FFY $0.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION

OR ATTACHMENT (if Applicable):

3.1-A, Page 3 3.1-A, Page 3 3.1-A, Exhibit 6b 4.19-B, Page 6b 4.19-B, Page 6b

10. SUBJECT OF AMENDMENT: A technical correction to add Optometrist services as a covered service and update reimbursement language allowing optometrist coverage to all eligible beneficiaries, not just EPSDT beneficiaries. This correction will conform to current state law and federal regulations and allow Optometric service providers to participate in the Medicaid Electronic Health Record (EHR) incentive program for eligible professionals. 11. GOVERNOR’S REVIEW (Check One): [DX] GOVERNOR’S OFFICE REPORTED NO COMMENT (CD OTHER, AS SPECIFIED: (COMMENTS OF GOVERNOR’S OFFICE ENCLOSED [NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. eye ONS epee 16. RETURN TO:

rt David J. Dzielak, Ph.D. 13. TYPED NAME: Davidl J: Dzielak, Ph.D. Miss. Division of Medicaid

Attn: Kristi Plotner 550 High Street, Suite 1000 Jackson, MS 39201-1399

14. TITLE: Executive Director

15. DATE SUBMITTED:

FORM HCFA-179 (07-97)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

August 8, 2013

Dr. David J. Dzielak Executive Director Mississippi Division of Medicaid 550 High Street, Suite 1000 Jackson, Mississippi 39201-1399

RE: Title XIX State Plan Amendment, MS 13-007

Dear Dr. Dzielak:

We have reviewed the proposed Mississippi State Plan Amendment 13-007, which was submitted to the Atlanta Regional Office on June 25, 2013. The SPA requests prior authorization for certain advanced imaging procedures except when performed during an inpatient hospitalization, an emergency room visit, or during a twenty-three (23) hour observation period. Prior authorizations are performed by a Utilization Management and Quality Improvement Organization (UM/QIO) contractor for the Division of Medicaid.

Based on the information provided, the Medicaid State Plan Amendment GA 13-007 was approved on August 8, 2013. The effective date of this amendment is July 1, 2013. We are enclosing the approved HCFA-179 and the plan pages.

If you have any additional questions or need further assistance, please contact Tandra Hodges at (404) 562-7409 or Tandra.Hodges@cms.hhs.gov.

Sincerely,

/s/

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1-A MEDICAL ASSISTANCE PROGRAM

Page 1

State of Mississippi TN No. 2013-007 Date Received 06-25-13 Supercedes Date Approved 08-08-13 TN No. 92-04 Date Effective 7/01/2013 AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

1. Inpatient hospital services other than those provided in an institution for mental diseases.

Provided: No Limitations With Limitations

2. a. Outpatient hospital services.

Provided: No Limitations With Limitations

b. Rural health clinic services and other ambulatory services furnished by a rural health clinic (which are otherwise included in the State plan).

Provided: No Limitations With Limitations

Not Provided

c. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with section 4231 of the State Medicaid Manual (HCFA-Pub. 45-5).

Provided: No Limitations With Limitations

3. Other laboratory and x-ray services.

Provided: No Limitations With Limitations

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 4.19-B MEDICAL ASSISTANCE PROGRAM

Page 3

State of Mississippi METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - OTHER TYPES OF CARE

Independent Laboratory and X-Ray Services - Payment is made from a statewide uniform fee schedule based on 90 percent of the current Medicare fee schedule and is updated each year as of July 1st and is effective for services provided on or after that date. All fees are published on the agency’s website at http://www.medicaid.ms.gov/FeeScheduleLists.aspx. Not withstanding any other provision of this section, the Division of Medicaid, as required by state law, shall reduce the rate of reimbursement to providers for any service by five percent (5%) of the allowed amount for that service.

TN# 2013-007 Date Received: 06-25-13 Supersedes

Date Approved: 08-08-13 TN# 2002-06

Date Effective:07-01-13

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachment 3.1-A MEDICAL ASSISTANCE PROGRAM

Exhibit 3

State of Mississippi TN No. 2013-007 Received 06-25-13 Supercedes Date Approved 08-08-13 TN No. New Date Effective 7/01/2013

DESCRIPTIONS OF AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

3. For dates of service on or after July 1, 2013, prior authorization is required for certain advanced imaging procedures. Prior authorization is performed by a Utilization Management and Quality Improvement Organization (UM/QIO) contractor for the Division of Medicaid.

Prior authorization for certain advanced imaging procedures, as specified in the MS Administrative Code, Title 23, Part 220, is required except when performed during an inpatient hospitalization, during an emergency room visit or during a twenty-three (23) hour observation period.

The Division of Medicaid covers all medically necessary services for EPSDT-eligible beneficiaries without regard to service limitations and with prior authorization.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

TRANSMITTAL.AND NOTICE OF APPROVAL OF | 1 TRANSMITTAL NUMBER: 2 STATE STATE PLAN MATERIAL 2013-007 | Ms

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE FOR: CENTERS FOR MEDICARE AND MEDI R ‘AR ICAID SERVICES | © cOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE AND MEDICAID SERVICES | July 1, 2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES i

5. TYPE OF PLAN MATERIAL (Check One):

(NEW STATE PLAN (0 AMENDMENT TO BE CONSIDERED AS NEW PLAN {J AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7, FEDERAL BUDGET IMPACT: 42 CFR §§ 431,10(e), 440.230(d) a.FFY 2013 ($450,000)

b. FFY 2014 ($1,800,000)

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

Attachment 3.1-A page I Attachment 3.1-A page ! New Attachment 3.1-A Exhibit 3

10. SUBJECT OF AMENDMENT: To require prior authorization for certain advanced imaging procedures except when performed during an inpatient hospitalization, during an emergency room visit or during a twenty-three (23) observation period.

11. GOVERNOR'S REVIEW (Check One): [J GOVERNOR'S OFFICE REPORTED NO COMMENT (OTHER, AS SPECIFIED: . COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

| 16. RETURN TO:

David J. Dzielak

Miss. Division of Medicaid Atte: Kristi Plotner

550 High Street, Suite 1000 Jackson, MS 39201-1399

14. TITLE: Executive Director

15. DATE SUBMITTED: JUN 2 6 7012

i FOR REGIONAL OFFICE USE ONLY

"17. DATE RECEIVED: 18. DATE APPROVED: 08-08-13

06-25-13

| PLAN APPROVED - ONE COPY ATTACHED

"19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. [ATURE OF NAL OFFICIAL: ‘0701/13 3 POA ce Sb Chk.

"21. TYRED NAME: 22..TITLE: Associate Regional Administrator

| JackieGlaze Division of Medicaid & Children Health Opns

| 23. s

with the following changes to items 8 and 9 as suthorized by State Agency c-mail dated 07/26/13. ! Atch 3.1-A Page 1; Atch 3.1-A Exhibit 3 and 4.19-B Page 3. Ach 3.1-A Page t; Aich 3.1-A Exhibit 3(new) and 4.19-B Page 3.

Table of Contents State/Territory Name: Mississippi State Plan Amendment (SPA) #: 13-013 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303 CMS CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS January 17, 2014 Dr. David J. Dzielak Executive Director Mississippi Division of Medicaid 550 High Street, Suite 1000 Jackson, Mississippi 39201-1399 RE: Title XIX State Plan Amendment, MS 13-013 Dear Dr. Dzielak: We have reviewed the proposed Mississippi State Plan Amendment 13-013, which was submitted to the Atlanta Regional Office on December 16,2013. The SPA is submitted as a technical change to add CMS mandated language to Attachment 3.1-A, Page 7, Number 18, adding the option that hospice care is provided in accordance with section 2302 of the Affordable Care Act. Based on the information provided, the Medicaid State Plan Amendment MS 13-013 was approved on January 17,2014. The effective date ofthis amendment is October 1, 2013. We are enclosing the approved HCF A-179 and the plan pages. If you have any additional questions or need further assistance, please contact Tandra Hodges at (404) 562-7409 or Tandra.Hodges@cms.hhs.gov. Sincerely, /Is// Jackie Glaze Associate Regional Administrator Division of Medicaid & Children's Health Operations Enclosures

DEPARTMENT OF:: 1\LTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: STATE PLAN MATERIAL 2013-013 3. PROGRAM IDENTIFICATION: FORM APPROVED OMB NO 0938-0193 2. STATE MS FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 4. PROPOSED EFFECTIVE DATE 10/112013 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [8] AMENDMENT COMPLETE BLOCKS 6 THRU I 0 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CJTATION: 7. FEDERAL BUDGET IMPACT: Social Security Act § 1905 ( o ); Affordable Care Act § 2302 $0.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 3.1-A page 7 Attachment 3.1-A page 7 10. SUBJECT OF AMENDMENT: State Plan Amendment (SPA) 2013-13 Hospice Care is to add language to Attachment 3.1-A page 7, #18, mandated by the Centers for Medicare and Medicaid (CMS) which adds the option that hospice care is "Provided in accordance with section 2302 of the Affordable Care Act". This is a technical change because the Division of Medicaid currently covers both curative treatment and palliative care for beneficiaries under the age of 21 under the hospice benefit. 11. GOVERNOR'S REVIEW (Check One): [8] GOVERNOR'S OFFICE REPORTED NO COMMENT 0 OTHER, AS SPECIFIED: 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: 1---------:----=--:--:-:------------J David J. Dzielak 13. TYPED NAME: David J. Dzielak Miss. Division of Medicaid 1--=-----=----:---=-:----------------J Attn: Kristi Plotner 14. TITLE: Executive Director 550 High Street, Suite 1000 1-15-. =D-:A-==T==E-=s=u=B=-=M-=I=T=T==E=D-: 712=--716-=--713;:-------------; Jackson, MS 39201-1399 17. DATE RECEIVED: 12-16--13 19. EFFECTIVE])ATEQF APPR.OVEDMJ\TER.l.AL:. 10/01113 21. TYPED NAUE: Jackie Glaze 23. REMARKS: FORM HCF A-179 (07-92) 1 ~t DATE APPROVED: 01-17-14 ns

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM Attachment 3.1-A Page 7 State of Mississippi AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 15. Services in an intermediate care facility for the mentally retarded (other than in an institution for mental diseases) for individuals who are determined in accordance with section 1902(a)(31 )(A), to be in need of such care. Provided: D No Limitations [81 With Limitations* D Not Provided 16. Inpatient psychiatric facility services for individuals under 22 years of age. Provided: D No Limitations [81 With Limitations* D Not Provided 17. Nurse-midwife services. Provided: D No Limitations [81 With Limitations* D Not Provided 18. Hospice care (in accordance with section 1905(o) ofthe Act). Provided: D No Limitations [81 With Limitations* L8J Provided in accordance with section 2302 of the Affordable Care Act D Not Provided *Description provided on attachment T~ No. 2013-013 Supercedes TNNo. 91-23 Date Received 12-16-13 Date Approved 01-17-14 Date Effective 10/01/2013

Table of Contents

State/Territory Name: Mississippi State Plan Amendment (SPA)#: 13-017

This file contains the following documents in the order listed:

1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

November 21, 2013

David J. Dzielak Mississippi Division of Medicaid Attn: Kristi Plotner 550 High Street, Suite 1000 Jackson, MS 39201-1399

Re: Title XIX State Plan Amendment, MS 13-017

Dear Mr. Dzielak:

We have reviewed the proposed State Plan amendment MS 13-017, which was submitted to the Atlanta Regional Office on November 6, 2013. This amendment continues coverage of pregnant minors (under age 19), regardless of income, who qualify under 42 CFR § 435.22 and Non-IV-E Adoption Assistance Children qualifying under 42 CFR § 435.227, regardless of income.

Based on the information provided, the Medicaid State Plan amendment MS 13-017 was approved on November 19, 2013. The signed CMS-179 and the approved plan pages are enclosed. The effective date of this amendment is December 31, 2013.

If you have any additional questions or need further assistance, please contact Rita Nimmons at (404) 562-7415 or Rita.Nimmons@cms.hhs.gov.

Sincerely,

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

DEPARTMENT OF HE:>.LTH AND HUMAN SERVICES CENTERS FOR Mf'DICARF AND MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL I L TRANSMITTAL NUMBER: 2013-017 FORM API'ROVH) OMB NO. ()931!-Ql'lJ 12. STATE MS --~---- 1 FOR: CENTERS FORMEDICARE AND MEiliCAlO SERVICES 3. PROGRAM IDENTIFICATION; TITLE XIX OF THE SOCIAL SECURrTY ACT (MEDICAID) ------ ·--- TO: REGIONAL ADMINISTRATOR 4. EFFECTIVE CENTE~S FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES December 31,2013 5. TYPE OF ~\NMA TERiAL (Check -One): 0 NEW S TE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [g) AMENDMENT ·····---~·······~-----==-- -~--~~ .. f...-.. ~.........:§:!:~~!3.1::2CKS 6 THRU 10 IF THIS IS AN AMENDMENT Se araJ.~}!:.!!fiSfl!_illalfor each amendment) ______ , __ , __ _ 6. FEDERAL;STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: SSA § 1902(~)(10)(A)(i)(IV), (r)(2); 41 CFR §§ 435.222,435.227 a. FFY 2014 $0.00 b. FFY 2015 $0.00 8. PAGE NUMBE.R OF THE PLAN SECTION OR ArrACHMENT: Suppleme* I to Attachment 2.2-A Page l Suppleme~t Sa to Attachment 2.6-A Page 5 -New 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (lj Applicable): Supplement I to Attachment 2.2-A -----------=+-~---:=---------------l......----------------~·---- 10. SUBJECll OF AMENDMENT: State Plan Amendment (SPA) 2013-017 Eligibility for Pregnan·t· Minors and Non-JV-E Adoption Assistance Children is being su~mitted to continue coverage of pregnant minors (under age 19), regardless of income, who qualify under 42 CFR § 435.222 and Non-JV-E Adoption Assistance Children qualifying under 42 CFR § 435.227, regardless of mcome. EW t'8J GOVERNOR'S OFFICE REPORTED NO COMMENT 0 OTHER. AS SPECIFIED: 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMlTTAL 16. -! David J. Dzielak ---.--:--=:~=--:::.+---~·~ ........................ _,, __ _ 14. TITLE: Executive Director Miss. Division of Medicaid -----------1 Attn: Kristi Plotner 550 High Street, Suite J 000 ---:-c:--=--::::~~~==-=-·-·····-.............. ___________ 1 Jackson, MS 39201-1399 15. DATE SUBMITTED: I , •• ~ 17. DATE R£K;EIVED: 11-06-q llUV 0 • w FOR REGION DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 23. REMARKS: Is I 22.TITLE: Associate Regional Administrator Division of Medicaid & Children Health Opns

Revision: HCFA-PM-91-4 (BPD)

SUPPLEMENT 1 TO AUGUST 1991

ATTACHMENT 2.2-A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Mississippi

REASONABLE CLASSIFICATIONS OF INDIVIDUALS UNDER

THE AGE OF 21, 20, 19, AND 18

7.b(6)

Other defined groups:

Division of Medicaid 1. Individuals making a transition from foster care to independent living arrangements (who are under 21 years of age), with all or part of their maintenance costs paid by a public agency of this state.

2. Pregnant minors under the age of 19 who live with or separately from parent(s) who are not otherwise eligible in any mandatory or optional categorically needy covered group that provides full Medicaid coverage.

______________________________________________________________________________ TN No. 2013-017______ Approval Date 11-19-13 Effective Date 12/31/2013 Supersedes TN No. 2004-010

HCFA ID: 7983E

Revision: HCFA-PM-91-4 (BPD) SUPPLEMENT 8a TO ATTACHMENT 2.6-A August 1991 Page 5 OMB No.: 0938-

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: Mississippi____________

MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902(r)(2) OF THE ACT

___ Section 1902(f) State X Non-Section 1902(f) State

5. The following liberalized income policy applies to all pregnant minors under the age of 19 qualifying for Medicaid under 42 CFR 435.222 as a reasonable classification of covered children:

• All income is disregarded – no income test applies.

6. The following liberalized income policy applies to all non-IV-E Adoption Assistance children qualifying under 42 CFR 435.227:

• All income is disregarded – no income test applies.

___________________________________________________________________________ TN No. 2013-017 Approval Date: 11-19-13

Effective Date 12/31/2013 Supersedes TN No. _New___ Date Received 11-06-13

HCFA ID: 7985E

Table of Contents State/Territory Name: Mississippi State Plan Amendment (SPA) #:13-0019-MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

January 3, 2014

David J. Dzielak Mississippi Division of Medicaid Attn: Kristi Plotner 550 High Street, Suite 1000 Jackson, MS 39201-1399

RE: Title XIX State Plan Amendment (SPA), MS 13-0019-MM1

Dear Mr. Dzielak:

The Centers for Medicare & Medicaid Services (CMS) has completed its review of State Plan Amendment (SPA), Transmittal Number MS-13-0019-MM1. This SPA was received by the CMS on December 19, 2013 to incorporate mandatory and optional Modified Adjusted Gross Income (MAGI) based eligibility groups into the Medicaid state plan in accordance with the Affordable Care Act. This SPA was approved on December 31, 2013 with an effective date of January 1, 2014.

The new pages listed below should be placed in a separate section at the back of the state plan:

• S14, Pages 1-5 • S25, Pages 1-3 • S28, Pages 1-2 • S30, Pages 1-5 • S32, Page 1 • S33, Page 1 • S50, Page 1 • S51, Page 1 • S52, Pages 1-10 • S53, Pages 1-2 • S54, Page 1 • S55, Page 1 • S57, Pages 1-2 • S59, Page 1

In addition, the new page titled “Superseding Pages of the State Plan Material,” should be placed in a separate section in the front of the approved SPA.

David J. Dzielak Page 2

Congratulations to you and your staff for your hard work and strong collaboration. If you have any additional questions or need further assistance, please contact Tandra Hodges at (404) 562-7409 or Tandra.Hodges@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Mississippi

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-13-019

Proposed Effective Date

| 01/01/2014 : ~ (mm/dd/yyyy )

Federal Statute/Regulation Citation

| 42 CFR 43!

Federal Budget Impact

Federal Fiscal Year

Amount

First Year

2014

| 2000000.0' $

Second Year

2015

ii

gl 4000000.0'

Subject of Amendment

Character counts out of 2000

$25 - $28 - $30 - $33 -

Parents and Other Careta «= Pregnant Women

Infants and Chikdren unde Former Foster Care Child! +

>

« Governor's Office Review

Cc . ° Governor's office reported no comment

° Comments of Governor's office received

Describe:

Character count dl out of 2000

Approved + v

c

° No reply received within 45 days of submittal Cc _

° Other, as specified Describe:

4 aj of

e Signature of State Agency Official

o Submitted By: Margaret Wilson

o Last Revision Date: Dec 30, 2013

o Submit Date:

Dec 19, 2013

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

STATE:

13-019 MAGI-Based Eligibility Group SPA Mississippi

Pages or sections of pages being superseded by S25, S28, S30, $51, S52, S53, S54, S57, and S14 and related pages or sections of pages being deleted as

obsolete State Plan Section Complete Pages Removed Partial Pages Removed Page 1 Page 2, A.2.b Page 3 Page 2, A.2.c Page 3a Page 2a, A. 3. Page 4 Page 5, A.10. Page 4a Page 9c, B.1 for Page 12 caretaker relatives Page 13 & pregnant women Page 13a Page 20, B.14 Page 14 Page 23c, B.19 Attachment 2.2-A Page l4a Page 23f, B.23 Page 21 Page 25, C.4. Page 23 Page 23b Page 23d Page 23g supp tement 1 to Attachment Page 1 Page 3b Page 1, A.2.a.(i) & Page lla (iii) Page 19 Page 6 related to Page 19a AFDC recipients, Page 19b pregnant women, Attachment 2.6-A Page 21 infants, and children Page 7, 1l.a(l) & (2) Page 12, 5.e.(2) Page 18, 5.e Page 25, 1l.a.(3) Supplement 1 to Attachment Pages 1-4

2.6-A

Supplement 2 to Attachment Pages 1-5 2.6-A Supplement 5 to Attachment Page 1 2.6-A Supplement 5a to Attachment Page 1 2.6-A Page 5 Page 3, #2 Supplement 8a to Attachment 2.6-A Supplement 12 to Attachment Pages 1-3

2.6-A

ccms Medicaid Eligibility

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

Enter the AFDC Standards below. All states must enter:

MAGIT-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996

Entry of other standards is optional.

The standard is as follows:

@ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

Additional incremental amount Household size | Standard ($) @ Yes CNo + | 227 » 4 Increment amount $ |78 +2 306 x +3 384 x +4 462 x +)5 541 x +\6 619 x +\7 697 x +/8 775 x

The dollar amounts increase automatically each year C Yes @ No

AFDC Payment Standard in Effect As of July 16, 1996

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi 814-1

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

C Standard varies in some other way

: Additional incremental amount Household size | Standard ($) @ Yes CNo +): 218 x Increment amount $ |75 +2 293 x +3 368 x +4 443 xX +/5 518 4 +16 593 x +17 668 x +]/s 743 4

The dollar amounts increase automatically each year C Yes @No

ayment Standard

[Income Standard Entry - Dollar Amount - Automatic Increase Option 7 Sia

The standard is as follows:

@ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

[Enter the statewide standard

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $14-2

CCMSsS Medicaid Eligibility

Household size | Standard ($) ov ow smo’ +i 227 xX Increment amount $ |78 +/2 306 x *+/3 384 x #4 462 x #15 541 xX *16 619 x #17 697 xX +/8 715 x

The dollar amounts increase automatically each year C Yes @ No

AFDC Need Standard in Effect As of July 16, 1996

Income Standard Entry - Dollar Amount - Automatic Increase Option Si3a

The standard is as follows:

C Statewide standard

C Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

The doilar amounts increase automatically each year C Yes (© No

[AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date.

Income Standard Entry - Dollar Amount - Automatic Increase Option S13a

The standard is as follows:

TN No: 13-0019-MM1 A Mississippi ae Date: 12-31-13 Effective Date: 01-01-14

Cer YON NCA A DATA EAC

CCMS Medicaid Eligibility

C Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year C Yes (No

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

C Standard varies in some other way

The dollar amounts increase automatically each year C Yes C No

TANF payment st

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

C Standard varies in some other way

The dollar amounts increase automatically each year C Yes CNo

MAGI-cquivalent TANF payment standard

TN No: 13-0019-MM1

Approval Date: 12-31-13 Mississippi

S14-4

Effective Date: 01-01-14

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

C Standard varies in some other way

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

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi 814-5

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

42 CFR 435.110 1902(a)(10)(A)(i)(1) 1931(b) and (d)

below a standard established by the state.

The state elects the following options:

technical training.

least one parent.

@ Other less restrictive standard

iw Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or

The state attests that it operates this eligibility group in accordance with the following provisions: [B] Individuals qualifying under this eligibility group must meet the following criteria: q 8 gibility group 8

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

This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, (0 provided the children are full-time students in a secondary school or the equivalent level of vocational or

[] Options relating to the definition of caretaker relative (select any that apply): Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or C care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at 7 The child must be deprived of parental support or care, but a less restrictive standard is used to measure

unemployment of the parent (select the one that applies):

C The principal earner may work 100 or more hours per month and still qualify as unemployed.

Indicate the number of hours used: [| hours

C The principal earner may earn up to a specific dollar amount and still qualify as unemployed.

Indicate the specific dollar limit of earnings: $

Name of other standard

Description

Under-employed

+

Two-parent households are only required to have income below the state established need standard xX for the family size.

TN No: 13-0019-MM1 Mississippi 825-1

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

Approval Date: 12-31-13 Effective Date: 01-01-14

Medicaid Eligibility

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

[@] Income standard used for this group

{@) Minimum income standard

The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards.

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

[=] Maximum income standard

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

An attachment is submitted.

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

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

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

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

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

Enter the amount of the maximum income standard:

C A percentage of the federal poverty level: %

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The

@ standard is described in S14 AFDC Income Standards.

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

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi 825-2

cCcmMs. Medicaid Eligibility

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

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

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

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

C Yes (@No

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $25-3

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

e

42 CFR 435.116

1902(a)(10)(A)(i)(IT) and (TV) 1902(a)(10)(A)(ii)(1), (TV) and (IX) 1931(b) and (d)

1920

[m) Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. The state attests that it operates this eligibility group in accordance with the following provisions: [MW Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4.

Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110.

@ Yes C No

wl MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S]0 MAGI-Based Income Methodologies, completed by the state.

[mi] Income standard used for this group [® Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.)

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

@ Yes (CNo

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

{@) Maximum income standard

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

An attachment is submitted.

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

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(TII) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10)

e (A)(ii)(D (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi 828-1

CCmMsS Medicaid Eligibility

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

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

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

C 185% FPL

The amount of the maximum income standard is:} 194 % FPL.

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

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

[W) Presumptive Eligibility

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

C Yes (@ No

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

TN No: 13-0019-MMI1 Approval Date: 12-31-13

N No: 13- Effective Date: 01-01-14 Mississippi S28-2

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

42 CFR 435.118

1902(a)(10)(A)()(IID, (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX)

1931(b) and (d)

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

The state attests that it operates this eligibility group in accordance with the following provisions: {@) Children qualifying under this eligibility group must meet the following criteria: [fm] Are under age 19 [BH] Have household income at or below the standard established by the state.

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

{@] Income standard used for infants under age one {@] Minimum income standard

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

@ Yes (No

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

[S| Maximum income standard

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

An attachment is submitted.

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

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II1) (qualified children), 1902(a)(10)(A)(i)(TV) (mandatory poverty level-related

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi 830-1

CPP TON LEDC ANS & MEDICA LEVIS

Medicaid Eligibility

Cc

Cc

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

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

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

185% FPL

Enter the amount of the maximum income standard: }194 % FPL

[@] Income standard chosen

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

@

The maximum income standard

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

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

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

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

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

[| Income standard for children age one through age five, inclusive

[=] Minimum income standard

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14

Mississinni

830-9

Cems Medicaid Eligibility

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

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

An attachment is submitted.

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

The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(IID) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Ce

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

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

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

Enter the amount of the maximum income standard: |143 % FPL

[W] Income standard chosen The state's income standard used for children age one through five is:

@ The maximum income standard

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

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

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

TN No: 13-0019-MMI1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $30-3

CEMS __ Medicaid Eligibility

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

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

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. [B] Income standard for children age six through age eighteen, inclusive [=] Minimum income standard The minimum income standard used for this age group is 133% FPL. [@] Maximum income standard

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

An attachment is submitted.

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

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IM) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Cc

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

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

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

@ 133% FPL

[Income standard chosen

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $30-4

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

1902(a)(10)(A iV) 42 CFR 435.119

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

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $32

ccms. Medicaid Eligibility

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

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

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

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

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

Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state [im] plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program.

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

C Yes @No

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

C Yes (@No

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

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $33

Medicaid Eligibility

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

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

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

C Yes @No

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi 850

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

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

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

C Yes @ No

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

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

TN No: 13-0019-MM1

Mississippi Approval Date: 12-3 1-13

a Effective Date: 01-01-14

CcmMs Medicaid Eligibility

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

42 CFR 435.222 1902(a)(10)(A)(ii)(D) 1902(a)(10A)(ii\(TV)

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

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

mw Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria:

[M) Be under age 21, or a lower age, as defined within the reasonable classification.

ww Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification.

[J Not be eligible and enrolled for mandatory coverage under the state plan.

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

The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age.

@ Yes C No

The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age.

@ Yes © No Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010

The state attaches the approved pages from the Medicaid state plan as of March 23, 2010 to indicate the age groups, reasonable classifications, and income standards used at that time for this eligibility group.

An attachment is submitted.

Current Coverage of All Children under a Specified Age

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $52-1

Medicaid Eligibility

The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid state plan as of March 23, 2010, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income.

C Yes @No

Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010

The state covers reasonable classifications of children previously covered in the Medicaid state plan as of March 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/or income standard for this classification covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income.

@ Yes C No

Indicate the reasonable classifications of children that were covered in the state plan in effect as of March 23, 2010 with income standards higher than the mandatory standards used for the child's age, using age limits and income standards that are not more restrictive than used in the state plan as of as March 23, 2010 and are not less restrictive than used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010

Reasonable Classifications of Children , S11

Individuals for whom public agencies are assuming full or partial financial responsibility. Individuals placed in foster care homes by public agencies Indicate the age which applies: (@ Under age 21 ( Underage 20 (Underage 19 ( Under age 18

(J Individuals placed in foster care homes by private, non-profit agencies

Individuals placed in private institutions by public agencies Indicate the age which applies: (@ Under age 21 + (C Under age 20 ( Underage 19 ( Under age 18

(1 Individuals placed in private institutions by private, non-profit agencies

{X] Individuals in adoptions subsidized in full or part by a public agency Indicate the age which applies: (@ Under age 21 ( Underage 20 ( Underage 19 ( Under age 18

(1 Individuals in nursing facilities, if nursing facility services are provided under this plan

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $52-2

Medicaid Eligibility

oO Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan

(C] Other reasonable classifications

Enter the income standard used for these classifications. The income standard must be higher than the mandatory standard for the child's age. It may be no lower than the income standard used in the state plan as of March 23, 2010 and no higher than the highest standard used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

| Click here once S11 form above is complete to view the income standards form. |

[@] Income standard used

[®] Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income

Standards. [8] Maximum income standard

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

December 31, 2013.

C Yes @ No

The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility

group.

An attachment is submitted.

The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is:

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

The state's effective income level for this classification of children under the Medicaid state plan C as of December 31, 2013, converted toa MAGI-equivalent percent of FPL or amounts by household size.

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $52-3

Medicaid Eligibility

Cc Ce

The state's effective income level for this classification of children under a Medicaid 1115 C Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for this classification of children under a Medicaid 1115 C Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

C A percentage of the federal poverty level: %

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is C described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

C Other dollar amount

[B) Income standard chosen

Individuals qualify under this classification under the following income standard:

The minimum standard. The maximum income standard.

If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

TN No: 13-0019-MM1

Mississippi

Approval Date: 12-31-13 Effective Date: 01-01-14 $52-4

Medicaid Eligibility

Another income standard in-between the minimum and maximum standards allowed, provided it is C higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent.

[i] Income standard used

[8] Minimum income standard

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

[=] Maximum income standard

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

C Yes @ No

The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the 4 maximum income standard to be used for this classification of children under this eligibility

group.

An attachment is submitted.

The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is:

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

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

The state's effective income level for this classification of children under a Medicaid 1115 C Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for this classification of children under a Medicaid 1115 C Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $52-5

Medicaid Eligibility

Cc C

C A percentage of the federal poverty level: %

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is C described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

C Other dollar amount

[i] Income standard chosen

Individuals qualify under this classification under the following income standard:

The minimum standard. The maximum income standard.

If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent.

Individuals in adoptions subsidized in full or part by a public agency

[@ Income standard used

[@ Minimum income standard

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14

Mississippi

852-6

Medicaid Eligibility

C Yes

The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards.

[=] Maximum income standard

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

@ No

The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the

4 maximum income standard to be used for this classification of children under this eligibility

group.

An attachment is submitted.

@

Cc

Cc

@

Cc

Cc

TN No: 13-0019-MM1

Mississippi

The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is:

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

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

The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

A percentage of the federal poverty level: %

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in $14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in $14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

Other dollar amount

Approval Date: 12-31-13 Effective Date: 01-01-14 852-7

Medicaid Eligibility

Cc e

[iB] Income standard chosen

Individuals qualify under this classification under the following income standard:

The minimum standard. The maximum income standard.

If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent.

Other Reasonable Classifications Previously Covered

The state covers reasonable classifications of children not covered in the Medicaid state plan as of March 23, 2010, but covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age

group. @ Yes

C No

The additional previously covered reasonable classifications to be included are:

Additional Previously Covered Reasonable Classifications Included

Reasonable Classifications of Children 2 Sil

(CJ Individuals for whom public agencies are assuming full or partial financial responsibility.

LJ Individuals in adoptions subsidized in full or part by a public agency

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14

Mississippi

$52-8

Medicaid Eligibility

(1 Individuals in nursing facilities, if nursing facility services are provided under this plan

o Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan

Other reasonable classifications

Name of classification Description Age Limit

Pregnant minors not otherwise eligible + Pregnant Minors for full Medicaid coverage in any other |/Under age 19 xX category of coverage

Enter the income standard used for these classifications (which must be higher than the mandatory standard for the child's age but may be no higher than the highest standard used in the state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013).

[ Click here once $11 form above is complete to view the income standards form.

Pregnant Minors

[m] Income standard used [i] Minimum income standard

The minimum income standard for this classification of children must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group.

[&] Maximum income standard

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

@ Yes (C No [@] No income test was used (all income was disregarded) for this classification under: (check all that apply) (1) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. (A Medicaid 1115 Demonstration as of March 23, 2010. (1 A Medicaid 1115 Demonstration as of December 31, 2013.

The state's maximum standard for this classification of children is no income test (all income is disregarded).

[8] Income standard chosen

Individuals qualify under this classification under the following income standard:

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi 852-9

Medicaid Eligibility

© This classification does not use an income test (all income is disregarded).

Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent.

Additional new age groups or reasonable classifications covered

If the state has not elected to cover the Adult Group (42 CFR 435.119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage.

The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted toa MAGI-equivalent standard.

C Yes (@ No [| There is no resource test for this eligibility group.

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $52-10

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

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

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

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

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

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

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

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

@ Yes (C No

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

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

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

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

[Minimum income standard

The minimum income standard for this eligibility group is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards.

[M| Maximum income standard

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 AAinnicoinni S53-1

Medicaid Eligibility

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

@ Yes C No

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

(D The Medicaid state plan as of March 23, 2010. [IX] The Medicaid state plan as of December 31, 2013. C1 A Medicaid 1115 Demonstration as of March 23, 2010. C1 A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). [M] Income standard chosen

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

C The minimum standard. @ This eligibility group does not use an income test (all income is disregarded).

Another income standard higher than both the minimum income standard and the effective income level for this eligibility group in the state plan as of March 23, 2010, converted to a MAGI-equivalent.

[m) There is no resource test for this eligibility group.

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $53-2

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

1902(a)(10)(A\(ii)(XTV) 42 CFR 435.229 and 435.4

1905(u)(2)(B)

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

C Yes (@ No

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi $54

Medicaid Eligibility

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

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

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

C Yes @ No

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi S55

Medicaid Eligibility

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

42 CFR 435.226 1902(a)(10)(A)(i)XVI)

Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226.

@ Yes (No

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

[@] Individuals qualifying under this eligibility group must meet the following criteria: {W Are under the following age @ Under age 21 C Under age 20 C Under age 19

[§) Were in foster care under the responsibility of a state on their 18th birthday. {@ Are not eligible and enrolled for mandatory coverage under the Medicaid state plan. [Have household income at or below a standard established by the state.

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

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

@ Yes (No

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

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

liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration

as of March 23, 2010 or December 31, 2013):

C Allchildren under the age selected

@ A reasonable classification of children under the age selected:

Individuals for whom foster care maintenance payments or independent living services were furnished under a program funded under title IV-E before the date the individual tured 18 years old.

@ Other reasonable classification

independent foster care adolescents who are in foster care under the responsibility of

Description : the Department of Human Services on their 18th birthday.

[| Income standard used for this eligibility group TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi 857-1

Medicaid Eligibility

[@) Minimum income standard

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

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

[i] Maximum income standard

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

@ Yes (CC No

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

The Medicaid state plan as of March 23, 2010. IX] The Medicaid state plan as of December 31, 2013. (1) A Medicaid 1115 demonstration as of March 23, 2010. (A Medicaid 1115 demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded).

{@] Income standard chosen Individuals qualify under this eligibility group under the following income standard: This eligibility group does not use an income test (all income is disregarded).

{m@) There is no resource test for this eligibility group.

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

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

TN No: 13-0019-MM1 Mississippi S a7) oval Date: 12-31-13 Effective Date: 01-01-14

Medicaid Eligibility

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

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

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

C Yes @ No

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

TN No: 13-0019-MM1 Approval Date: 12-31-13 Effective Date: 01-01-14 Mississippi S59

Table of Contents State/Territory Name: Mississippi State Plan Amendment (SPA) #: 13-0022-MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

March 19, 2014

David J. Dzielak, Ph.D. Mississippi Division of Medicaid Attn: Kristi Plotner 550 High Street, Suite 1000 Jackson, MS 39201-1399

RE: Title XIX State Plan Amendment (SPA), MS 13-0022-MM5

Dear Dr. Dzielak:

The Centers for Medicare & Medicaid Services (CMS) has completed its review of State Plan Amendment (SPA), Transmittal Number MS-13-0022-MM5. This SPA was received by the CMS on December 19, 2013 to affirm state residency regulations and addresses interstate agreements and temporary absence in accordance with the Affordable Care Act. This SPA was approved on March 19, 2013. The effective date of this SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the back of Mississippi’s approved state plan, as well as a summary of the state plan pages which are superseded by SPA 13-0022-MM5, which should be incorporated into a separate section in the front of the state plan.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any additional questions or need further assistance, please contact Tandra Hodges of my staff at (404) 562-7409 or Tandra.Hodges@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: Mississippi

Transmittal Number:

Please enter the Transmittal Number (TN) in the format ST-YY-O000 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.

M$-13-022

Proposed Effective Date

01/01/2014

[

(mm/dd/yyyy)

Federal Statute/Regulation Citation

| 42 CFR 43!

Federal Budget Impact

Federal Fiscal Year Amount

First Year | 2014 gl 0.00 Second Year | 2015 gl 0.00

Subject of Amendment

Character count out of 2000

fo}

State Residency 4

Governor's Office Review

Ec Governor's office reported no comment

E Comments of Governor's office received

Describe:

Character Count: out of 2000

Approved +

J Ll a

C No reply received within 45 days of submittal

c Other, as specified

4 LL ie

Signature of State Agency Official

Describe:

Submitted By: Margaret Wilson Last Revision Date: Dec 20, 2013

Submit Date: Dec 20, 2013

SUPERSEDING PAGES OF

STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13-0022 MMS Mississippi PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): S88 Non-Financial Eligibility- State Residency Section 2: Page 13, Item 2.3, TN 87-9 Attachment 2.6-A: Page 3, Item (4), TN 13-0023 MM6

ccms Medicaid Eligibility

RDU waa aah A care Gat bs

OMB Control Number 0938-1148

: OMB Expiration date: 10/31/2014 Non-Fie Eligibility

State Residency S88

42 CFR 435.403

State Residency

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

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

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

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

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

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

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

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

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

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

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

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

™ @

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

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

® @

IV-E eligible children living in the state, or

TN No: 13-0022-MM5 Approval Date: 03/19/14 Effective Date: 01/01/14 Mississippi S88-1

CcmMs Medicaid Eligibility

ONSO TO Gtrae oat ket Aas ne

{@] Otherwise meet the requirements of 42 CFR 435.403.

Approval Date: 03/19/14 Effective Date: 01/01/14

TN No: 13-0022-MM5 S88-2

Mississippi

CcmMsS

NCE Foe 0m aie A oar aad aN

Medicaid Eligibility

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

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

Alabama {X] Mlinois {X] Montana [K] Rhode Island —X] Alaska [X] Indiana {K] Nebraska South Carolina [X] Arizona iX] lowa IX] Nevada [X} South Dakota Arkansas ({K] Kansas {] New Hampshire Tennessee {X] California {K]} Kentucky X] New Jersey KX] Texas

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

[X}] Connecticut IX] Maine [| New York [X] Vermont

{K] Delaware [KX] Maryland North Carolina Virginia

[X] District of Columbia [KX] Massachusetts {X] North Dakota [X] Washington IX] Florida {X] Michigan Ohio 1] West Virginia [x] Georgia [K] Minnesota {X] Oklahoma &X} Wisconsin Hawaii J Mississippi Oregon CJ Wyoming {K] Idaho K]} Missouri Pennsylvania

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

Are IV-E eligible

(7 Are in the state only for the purpose of attending school

(J Are out of the state only for the purpose of attending school (1) Retain addresses in both states

£X) Other type of individual

Name of Type Description non-IVE adoption assistance children The interstate agreements in place with the MS Department Pp of Human Services allows non-IVE adoption assistance + children to be considered as part of the JCAMA compact x

provided the state of origin has a reciprocity clause in the interstate agreement; otherwisc, non-IVE adoption assistance children are not automatically considered residents.

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

TN No: 13-0022-MM5 Approval Date: 03/19/14 Effective Date: 01/01/14 Mississippi $88-3

Medicaid Eligibility

@ Yes C No

Provide a description of the policy:

An individual who is a full-time student in the State of Mississippi will not be considered a resident of Mississippi if all of 7 the following conditions exist: : - neither of the individual's parents reside in the State of Mississippi;

- the individual is claimed as a tax dependent by someone who resides in a state other than Mississippi; and

~ the individual is applying for coverage on his or her own behalf.

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

@ Yes © No

Provide a description of the definition:

The temporary absence of a MS Medicaid recipient from the state does not affect his/her residency in MS, provided | the absent recipient does not establish residency elsewhere and the absence is temporary, such as but not limited to 4 attending school or job training in another state or receiving medical treatment in another state. i

{

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 complcte this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, pather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance

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

TN No: 13-0022-MM5 Approval Date: 03/19/14 Effective Date: 01/01/14 Mississippi S88-4

Table of Contents

State/Territory Name: Mississippi State Plan Amendment (SPA) #: 13-0023-MM6

This file contains the following documents in the order listed:

1) Approval Letter

2) Summary Form (with 179-like data) 3) Superseding Pages Notice

4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

March 20, 2014

David J. Dzielak, Ph.D. Mississippi Division of Medicaid Attn: Kristi Plotner 550 High Street, Suite 1000 Jackson, MS 39201-1399

RE: Title XIX State Plan Amendment (SPA), MS 13-0023-MM6

Dear Dr. Dzielak:

The Centers for Medicare & Medicaid Services (CMS) has completed its review of State Plan Amendment (SPA), Transmittal Number MS-13-0023-MM6. This SPA was received by the CMS on December 19, 2013. SPA 13-0023-MM6 affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility in accordance with the Affordable Care Act. This SPA was approved on March 19, 2014. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the back of Mississippi’s approved state plan, as well as a summary of the state plan pages which are superseded by SPA 13-0023-MM6, which should be incorporated into a separate section in the front of the state plan.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any additional questions or need further assistance, please contact Tandra Hodges of my staff at (404) 562-7409 or Tandra.Hodges@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Mississippi

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-13-023

Proposed Effective Date

01/01/2014 (mm/dd/yyyy)

Federal Statute/Regulation Citation

1902(a)(4€

Federal Budget Impact

Federal Fiscal Year Amount

First Year 2014 $ 0.00 Second Year 2015 gl 0.00

Subject of Amendment

Citizenship and Non-Citizen P|

|

Governor's Office Review

c Governor's office reported no comment

fc Comments of Governor's office received

Describe:

Approved +

EC No reply received within 45 days of submittal

Cc Other, as specified

4

=i

Describe:

a) mal

Signature of State Agency Official Submitted By:

Margaret Wilson

Last Revision Date: Dec 20, 2013

Submit Date: Dec 20, 2013

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: STATE:

13-0023 MM6 Mississippi

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

S89 Non-Financial Eligibility- Citizenship and Non-citizen Eligibility Attachment 2.6-A: Page 2, item (3), subparagraphs (a), (b), (c), TN 92-03

Attachment 2.6-A: Page 3, item (3), subparagraphs (d) and (e), TN 92-03

Medicaid Eligibility

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

1902(a)(46)(B)

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

42 CFR 435.4

42 CFR 435.406

42 CFR 435.956

Citizenship and Non-Citizen Eligibility

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

{m] The state provides Medicaid eligibility to otherwise eligible individuals: CI] Who are citizens or nationals of the United States; and

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

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

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

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

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

@ Yes No

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

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

C Other date, as described:

TN No: 13-0023-MM6 Approval Date: 03/19/14 Effective Date: 01/01/14 $89-1

Medicaid Eligibility

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

C Yes (@No Indicate which requirements apply:

The state requires Lawful Permanent Residents to have 40 qualifying work quarters under Title Il of the Social Security Act. @Yes (No The state limits eligibility to 7 years for certain non-citizens. @yYes CNo Check all that apply: Non-citizens admitted to the U.S. as a refugee under section 207 of the INA XJ Non-citizens granted asylum under section 208 of the INA IX Non-citizens whose deportation is withheld under section 243(h) or 241(b)(3) of the INA

Non-citizens granted status as a Cuban-Haitian Entrant, as defined in section 501(e) of the Refugee Education Assistance Act of 1980

Non-citizens admitted to the U.S. as Amerasian

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

C Yes @No

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

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

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

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

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

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

[M] Granted employment authorization under 8 CFR 274a.12(c);

[8] Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

[mM] Under Deferred Enforced Departure (DED) in accordance with a decision made by the President;

TN No: 13-0023-MM6 Approval Date: 03/19/14 Effective Date: 01/01/14

S89-2

Medicaid Eligibility —

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

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

[M] Has been granted employment authorization; or

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

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

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

(D Other

The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following

individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN:

[@] Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613;

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

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

TN No: 13-0023-MM6 Approval Date: 03/19/14 Effective Date: 01/01/14 $89-3

Table of Contents

State/Territory Name: Mississippi State Plan Amendment (SPA) #: 13-0024-MM7

This file contains the following documents in the order listed:

1) Approval Letter 2) Summary Form (with 179-like data)

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

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

Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

March 20, 2014

David J. Dzielak, Ph.D. Mississippi Division of Medicaid Attn: Kristi Plotner

550 High Street, Suite 1000 Jackson, MS 39201-1399

RE: Title XIX State Plan Amendment (SPA), MS 13-0024-MM7 Dear Dr. Dzielak:

The Centers for Medicare & Medicaid Services (CMS) has completed its review of State Plan Amendment (SPA), Transmittal Number MS-13-0024-MM7. This SPA was received by the CMS on December 19, 2013. SPA 13-0024-MM7 establishes that one or more qualified hospitals are determining presumptive eligibility, and that the state is providing coverage for individuals determined presumptively eligible, in accordance with the Affordable Care Act. This SPA was approved on March 19, 2014. The effective date of the SPA is January 1, 2014.

As per our discussion, the state will not delay a presumptive eligibility determination if an individual does not provide all of the information needed for a MAGI-based determination.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the back of Mississippi’s approved state plan, as well as a summary of the state plan pages which are superseded by SPA 13-0024-MM7, which should be incorporated into a separate section in the front of the state plan.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any additional questions or need further assistance, please contact Tandra Hodges of my staff at (404) 562-7409 or Tandra. Hodges@cms.hhs. gov.

Sincerely,

/Is//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Mississippi

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-13-024

Proposed Effective Date

01/01/2014 (mm/dd/yyyy)

Federal Statute/Regulation Citation

42 CFR 43!

Federal Budget Impact

Federal Fiscal Year Amount

First Year 2014 $l 0.00 Second Year 2015 $l 0.00

Subject of Amendment

Character Count: out of 2000

Presumptive Bigiblity by sore]

fa Lt a

Governor's Office Review

c Governor's office reported no comment

cE Comments of Governor's office received

Describe:

Character Count: out of 2000

Approved +

= Lt a

c No reply received within 45 days of submittal

c Other, as specified

Describe: _] _t a Let zal

Signature of State Agency Official Submitted By:

Margaret Wilson Last Revision Date: Dec 20, 2013

Submit Date: Dec 20, 2013

Medicaid Eligibility

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

42 CFR 435.1110

One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision.

@Yes (No

The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: {@) A qualified hospital is a hospital that: Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of

[i] its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance

iC with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency.

Assists individuals in completing and submitting the full application and understanding any documentation requirements.

@Yes CNo

{@) The eligibility groups or populations for which hospitals determine eligibility presumptively are:

[im Pregnant Women

[im] Infants and Children under Age 19

Parents and Other Caretaker Relatives

[i] Adult Group, if covered by the state

Individuals above 133% FPL under Age 65, if covered by the state

{@ Individuals Eligible for Family Planning Services, if covered by the state

[i] Former Foster Care Children

[@ Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state

(J) Other Family/Adult groups:

(J Eligibility groups for individuals age 65 and over

(CJ Eligibility groups for individuals who are blind

(CZ) Eligibility groups for individuals with disabilities

(C] Other Medicaid state plan eligibility groups

(J Demonstration populations covered under section 1115

The state establishes standards for qualified hospitals making presumptive eligibility determinations.

TN No: 13-0024-MM7 Approval Date: 03/19/14 $21-1

Effective Date: 01/01/14

Medicaid Eligibility

@yYes (CNo

Select one or both:

x The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period.

All hospitals newly electing HPE will be granted a 6-month implementation period during which time no performance standards will be imposed. This 6-month period begins after assigned hospital staff are trained and certified and begins submission of HPE decisions. During the implementation period, data will be collected by DOM regarding the number of HPE approvals that have a full Medicaid application submitted before the end of the HPE period of eligibility. This data will be provided to the HPE hospitals on a monthly basis or more frequently if needed. DOM will monitor this data and provide feedback directly to the hospital staff certified to make HPE determinations in order to align the hospitals with the expectations for the 2nd 6-month period when a standard of 90% will be applied as follows: at least 90% of all HPE approvals submitted to DOM result in a full Medicaid application submitted to DOM before the end of the HPE period of eligibility. The number of full applications that are not submitted timely and the number of HPE approvals that are placed on file that do not result in a full application cannot exceed 10% of the total number of HPE approvals submitted to DOM during a month. Exceptions will be granted on a case by case basis, e.g., a HPE applicant dies or an inpatient HPE applicant leaves the hospital on a week-end before the full application can be submitted. Although submission of a full Medicaid application is not a condition of eligibility for HPE, it is a performance standard established by the state to measure the extent to which individuals covered during a HPE period are encouraged and assisted by the hospital to submit a full Description of standards: japplication.

During the 2nd 6-month period, data collection and direct contact with the hospital will continue ‘on a monthly or as-needed basis. No hospital will be disqualified during the Ist 12 months of implementation of HPE. If the data collected during the first year of implementation suggests that a 90% accuracy rate for timely submissions of full Medicaid applications for HPE approvals is not an achievable standard for a particular hospital, discussions will be held with hospital staff regarding corrective actions needed, any training needed and any possible alternate standard that could be applied if the 90% standard could not be met due to circumstances beyond the hospital’s control.

Effective with the 2nd year of participation in HPE, the performance standards shown above for submission of full Medicaid applications prior to the end of the HPE period increases and remain at 95%. The possibility of an alternate standard assigned for a pre-determined amount of time will be discussed as a correction action measure if at any time a hospital falls below the 95% standard due to circumstances beyond their control. Feedback and direct contact with hospital staff will continue on an as-needed basis and data will be shared monthly regarding adherence to the performance standards.

& The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period.

All hospitals newly electing HPE will be granted a 6-month implementation period during which time no performance standards will be imposed. This 6-month period begins after assigned hospital staff are trained and certified and begins submission of HPE decisions. During the implementation period, data will be collected by DOM regarding: at least 90% of HPE approvals are determined to be Medicaid eligible based on submission of the full Medicaid application. A full application that does not confirm Medicaid eligibility for the HPE period of eligibility cannot exceed 10% of the total number of HPE approvals processed during a month. An applicant’s failure to complete the full application process with DOM will not count against the hospital.

TN No: 13-0024-MM7 Approval Date: 03/19/14 Effective Date: 01/01/14

$21-2

Medicaid Eligibility

During the 2nd 6-month period, data collection and direct contact with the hospital will continue on a monthly or as-needed basis. No hospital will be disqualified during the Ist 12 months of implementation of HPE. If the data collected during the first year of implementation suggests that a 90% accuracy rate for HPE approvals is not an achievable standard for a particular hospital, discussions will be held with hospital staff regarding corrective actions needed, any training needed and any possible alternate standard that could be applied if the 90% standard could not be met due to circumstances beyond the hospital’s control.

Description of standards:

Effective with the 2nd year of participation in HPE, the performance standards for the accuracy of the HPE decisions will increase and remain at 95%. The possibility of an alternate standard assigned for a pre-determined amount of time will be discussed as a corrective action measure if at any time a hospital falls below the 95% standard due to circumstances beyond their control. Feedback and direct contact with hospital staff will continue on an as-needed basis and data will be shared monthly regarding adherence to the performance standards.

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

[B] The end date of the presumptive period is the earlier of:

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

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

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

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

C Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. @ Yes C No

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

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

TN No: 13-0024-MM7 Approval Date: 03/19/14

$21-3

Effective Date: 01/01/14

Medicaid Eligibility

[Mf] The presumptive eligibility determination is based on the following factors:

The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is {ll being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group)

ci Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group.

DX] State residency XI Citizenship, status as a national, or satisfactory immigration status

The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 1f you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: 13-0024- MM7 Approval Date: 03/19/14

Sas Effective Date: 01/01/14

CALCULATING MAGI HOUSEHOLD (HH) INCOME (Handout #4)

Tax Filer Households (HH) Using Tax Filer Status

1.

Married Filing Jointly — HH includes both spouses & all tax dependents claimed (living together or separately) e HH income is the sum of the tax filer couple’s MAGI + the MAGI of each tax dependent that is “required to file.”

. Married Filing Separately — Each spouse has their HH computed

separately but each spouse is included in the other’s tax HH (if living together). e HH of each spouse includes both spouses + all tax dependents claimed. e HH income of each spouse includes the MAGI of each spouse + the MAGI of each tax dependent that is “required to file.”

. Unmarried tax filer couples (not a tax status) are not included in each

other’s HH. Each member of the couple would have their own HH. e HH of each member of the couple would include the tax filer + all dependents claimed.

e HH of each member of the couple includes the MAGI of the tax filer + the MAGI of each tax dependent that is “required to file.”

Tax Filer Status Declared as Head of Household, Qualifying Widow or Single -includes unmarried individuals with or without dependent(s) e HH includes tax filer + all tax dependents claimed, if any. e HH income includes the MAGI of the tax filer + the MAGI of each tax dependent (if any) that is “required to file.”

If a HH member is both a tax filer and a tax dependent, treat that individual under tax dependent rules described below.

1

Tax Dependent’s HH — a tax dependent may be a child (biological, adopted or step) or some other family member or non-family member (adult or child) who meets the requirements to be claimed as a tax dependent.

1. Each dependent’s HH is determined separately

e If dependent does not meet an exception, the HH and income of the dependent is the same as the tax filer’s HH unless:

v The tax dependent is married and living with his/her spouse in which case the dependent’s HH is increased by 1 to include the spouse. The spouse’s income, if required to file, would count towards dependent’s HH.

e A tax dependent meeting an exception is treated as a non-filer, counting MAGI of the dependent’s HH under non-filer rules described below.

e A tax dependent who is also a parent of a child or children living in the HH must have his/her income counted toward the child(ren) regardless of whether the dependent is “required to file.”

2. Exceptions to using tax filer HH rules for a tax dependent exists when:

e The tax dependent is not the tax filer’s spouse or child,

e The tax dependent, under age 19, lives with 2 parents (married or unmarried) who do not plan to file jointly,

e The tax dependent, under age 19, is claimed by a non-custodial parent.

Non-Filer Rules — apply to individuals who do not expect to file taxes, or

are not claimed as a tax dependent, or

are a tax dependent but meet an exception:

1. Adult Non-Filer

HH includes non-filer adult + spouse (if living with spouse) + child(ren) under age 19.

HH income includes the income of all HH members. Income of a child under age 19 is not counted unless “required to file.”

2. Child Non-Filer (Under Age 19)

HH includes non-filer child + parent(s) + siblings under age 19 living together.

HH income includes the income of all HH members. Income of a child is not counted unless “required to file.”

A child non-filer living with someone other than parent(s) has their income counted regardless of the “required to file” rule

A non-filer child who is also a parent of a child or children living in the HH must have his/her income counted toward the child(ren) regardless of whether the non-filer child is “required to file.”

3. Tax dependent child (under age 19) claimed by a non-custodial parent

In this situation, the child lives with the custodial parent, but is claimed by the non-custodial parent.

The child’s HH (for the child’s own eligibility) does include the custodial parent with whom the child lives + step-parent and siblings in the home, if any.

The child is not a HH member for the eligibility of the custodial parent with whom he/she lives or other members.

The child’s income (if required to file) does not count in the custodial parent’s HH.

e The child would be included as a tax dependent in the non-custodial parent’s HH for that HH’s eligibility.

Budgeting “Oddities” That You Need to Know — these are budgeting rules to keep in mind, in addition to those already described:

e A caretaker relative (and spouse, if applicable) can qualify for Medicaid even if the dependent child(ren) under age 18 for whom the relative is responsible cannot qualify due to excess income. Since the caretaker relative (and spouse) must be budgeted separately from the child(ren) in his/her/their care, it is possible for the child(ren) to have excess countable income that prohibits eligibility for Medicaid or CHIP while the caretaker relative is below the income limit for a household of one (or two, if there is a spouse). For example, a grandmother caring for her grandchildren under age 18 may have little or no income but the children receive Social Security or some other countable income on their own that makes the children’s budget group ineligible. However, the grandmother can qualify as a needy caretaker because she is the main person taking care of the children under age 18 and has low income and she is within the specified degree of relationship to the children.

e One parent who is a member of an unmarried tax filer or non-filer couple may be able to qualify as a low-income parent even when the other parent cannot qualify due to excess income. Since unmarried couples are budgeted separately (not included in each other’s budget group), it is possible for one member of the couple to qualify based on low income while the other parent does not. The parent must have a child of their own under age 18 in the home. For example, an unmarried couple with children. Father does not have income (or has income that does not count) and mother works. Father’s budget will be with his children and he can qualify based on low-income and his relationship to his children. Mother will not qualify in her budget group with her children due to income.

e An SSI recipient who gets both SSI and SS is included in the appropriate household budget group. Their SS is countable as income in the budget group if the SSI recipient is an adult or a child not living with a parent. The SSI is not countable as income, but the SS is income toward the budget group with the SSI recipient included as a HH member. For example, disabled mother receives SSI and SS (and Medicaid). If she applies for her children (and spouse, if any), her needs and her SS is counted in the budget with her children (and

spouse, if any).

Requirement to Convert Non-Monthly Income to Monthly for MAGI HH’s

Actual monthly income must be counted in most cases for MAGI purposes.

1.

2.

Weekly Earned Income — multiply a reported weekly amount by 4.33 to arrive at a monthly countable amount (use normal rounding rules). Bi-Weekly Earned Income (received every 2 weeks) — multiply a reported bi-weekly amount by 2.17 to arrive at a monthly amount.

Earnings reported from any source must be converted to a monthly amount based on the time period the payment is intended to cover, such as dividing net earnings from self-employment by 12 if the NESE was earned over an entire taxable year.

Recurring non-earned income reported from any source must be converted to a monthly amount based on the time period the payment is intended to cover.

CONSTRUCT A MAGI HOUSEHOLD

(HH) FOR EACH APPLICANT

(Handout #1)

DOES INDIVIDUAL EXPECT TO FILE TAXES?

YES

NO

Does individual expect to be claimed as a tax dependent?

Does individual expect to be claimed as a tax dependent?

YES NO

YES NO

HH consists of tax filer, spouse living with tax filer & all tax dependents expecting to be claimed.

Does individual meet any of the exceptions?

1. Expects to be claimed as a tax dependent of someone other than his/her

Does individual meet any of the | Treat as Non-filer exceptions?

1. Expects to be claimed as a tax dependent of someone other than his/her spouse or

parent.*

spouse or parent.* 2. Child under age 19 lives 2. Child under age 19 with both parents lives with both (married or unmarried) parents (married or who will not file a joint unmarried) who will return. not file a joint 3. Child under age 19 return. expects to be claimed 3. Child under age 19 by non-custodial parent. expects to be claimed by non- custodial parent. YES NO YES NO Treat as Apply tax Treat as | The HH is the HH Non-filer filer rules Non-filer | of the tax filer

claiming his/her as a dependent. If individual is married (& living with spouse), the HH also includes the individual's spouse.

NON-FILER: INDIVIDUAL DOES NOT EXPECT TO FILE TAXES AND IS NOT CLAIMED AS A

DEPENDENT OR IS A TAX DEPEN

DENT WHO MEETS AN EXCEPTION

The HH consists of the individual & if living with, the individual's spouse & children under age 19*

If individual is under age 19, the HH includes the individual’s parent(s)* (married or unmarried) and

siblings under age 19% living in the HH.

* Parent, Children & Siblings refer to the biological,

adopted or step parent, children or siblings.

A pregnant HH member (applying) is counted as herself + the number of babies expected for all HH members in her budget group for Medicaid (not CHIP) purposes. Pregnant minors qualifying on the basis of pregnancy are Medicaid eligible with a total disregard of income (parental, spousal, personal

income).

INCOME COUNTING RULES (Handout #3)

MAGI, or modified adjusted gross income, requires the use of IRS rules in determining income that counts, however there are some exceptions to using IRS rules.

Income that is not counted or is counted only under certain conditions:

e Alimony paid — alimony received is income but alimony paid is deducted as income from the payer.

e Child Support benefits — is not counted as income to the payee or child(ren) receiving the payment but is not deducted as income from the payer.

© Lump sum payments — whether recurring or non-recurring are counted as income in the month received and is not annualized.

© Self-employment — all IRS business deductions related to self-employment are allowable. Only net earnings from self-employment counts as income.

e VA benefits — all types of VA payments are not counted as income.

e Workers’ Compensation — is not counted as income.

e Supplemental Security Income (SSI) — is not counted as income.

e Certain income received by an American Indian or Alaska Native may be excluded if it involves the following types of income: distributions from Alaska Native Corporations and Settlement Trusts; distributions from any property held in trust located within the boundaries of a federal reservation; distributions and payments from rents, leases, rights of way, royalties, usage rights or natural resource extraction and harvest from rights of ownership in any reservation lands or federally protected rights regarding off-reservation hunting, fishing, gathering or usage of natural resources; distributions resulting from real property ownership interests related to natural resources and improvements located on or near a reservation; payment resulting from ownership interests and usage rights to items that have a unique religious, spiritual, traditional or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom; and student financial assistance provided under the Bureau of Indian Affairs programs.

Income that counts:

Social Security benefits received by an applicant. Social Security is income that counts unless it is received by a tax dependent or non-filer child who is not required to file, as explained in the “Required to File” rule. (Handout #5) Otherwise, count Social Security as income.

Wages, Salaries, Tips, Military Pay, Bonuses or Earnings of any type

Net Earnings from Self-Employment, Rental Income, Farming Income Retirement, Pension benefits, Annuity payments, Trust income

Interest, Dividends, Royalties

Any other income that counts under IRS rules.

When viewing a federal tax return, use the adjusted gross income from the 1040 form to obtain countable income after all allowable IRS adjustments. However, if any portion of Social Security benefits is not taxable for any adult filer in the household composition, add the non-taxable amount back as income. Keep in mind that you will not add back any Social Security received by a tax dependent or non-filer child who is not “required to file” a tax return.

Effective Month: March 2014

THIS CHART IS FOR HPE DECISION ONLY

MAGI Income Limits Effective March 1, 2014 with 5% FPL Disregard Handout #6

The 5% disregard has been added for each group below. This chart is for use with HPE decisions only and is not for public distribution.

Medicaid for Pregnant Women (any age) and Medicaid for Infants from Birth to Age 1

194% FPL

Family Size 1 2 3 4 5 6 7 8

Monthly Income | $1982 $2671 $3361 $4050 $4739 $5430 $6117 $6806

For more than 8 members add $691 for each additional person

Medicaid for Children Age 1 to Age 6

143% FPL

Family Size 1 2 3 4 5 6 7 8

Monthly Income | $1462 $1969 $2478 $2985 $3493 $4002 $4510 $5017

For more than 8 members add $509 for each additional person

Medicaid for Children Age 6 to Age 19

133% FPL

Family Size 1 2 3 4 5 6 7 8

Monthly Income | $1360 | $1831 | $2305 | $2777 | $3249 | $3722 | $4194 | $4666

For more than 8 members add $474 for each additional person

Parent(s) & Caretaker Relative(s) with Dependent Children under Age 18

Family Size 1 2 3 4 5 6 7 8

Monthly Income | $238 $321 $403 $485 $568 $650 $732 $814

For more than 8 members, add $78 for each additional person.

Breast & Cervical Cancer Program (limited to hospital screening providers only)

Family Size 1 2 3 4 5 6 7 8

Monthly Income | $2431 $3277 $4123 $4969 $5815 $6660 $7506 $8352

For more than 8 members, add $846 for each additional person.

10.

11.

12.

HOSPITAL PRESUMPTIVE ELIGIBILITY (HPE)

TRAINING MATERIAL AGENDA

. ACA COVERAGE CHANGES

QUALIFIED HOSPITALS HOSPITAL RESPONSIBILITIES DOM RESPONSIBILITIES PERFORMANCE STANDARDS

POPULATIONS ELIGIBLE FOR MEDICAID HPE

ELIGIBILITY REQUIREMENTS

HPE APPLICATION REQUIREMENTS FOR HPE DECISIONS HPE PERIOD OF ELIGIBILITY

MEDICAID COVERED BENEFITS FOR HPE APPROVALS

APPLICATION REQUIREMENTS FOR SUBMITTING FULL APPLICATIONS FOR HPE APPROVALS

THE HPE DETERMINATION PROCESS

e Handout #1 — Construct a MAGI Household for Each Applicant

e Handout #2 — Tax Filer & Non-Tax Filer Rules Chart

e Handout #3 — Income Counting Rules

e Handout #4 — Calculating MAGI Household Income

e Handout #5 — “Required to File” Rule for Counting the Income of a Tax Dependent or Non-Filer Child

e Handout #6 —- MAGI Income Limits (with the 5% FPL Disregard)

e Examples

13. The HPE Application Form & Instructions

14. Model Notice to Applicants

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ACA COVERAGE CHANGES

The Affordable Care Act (ACA) was signed into law in March 2010; it makes major changes to how people secure health coverage in the U.S. Coverage changes include:

¢ Medicaid and CHIP expansion and improvements e Health insurance marketplaces for individuals and small businesses, e Private insurance market reforms.

For Medicaid & CHIP, the changes include:

e Use ofa single, streamlined application form to apply for Medicaid, CHIP and premium tax credits available through the federal marketplace used by Mississippi,

e Use of MAGI or Modified Adjusted Gross Income as the new method for determining eligibility for children, parent(s) or caretaker relatives and pregnant women.

e Medicaid expansion for children — all children up to age 19 with family incomes up to 133% of the federal poverty level are now Medicaid eligible,

¢ Hospitals can now determine individuals to be presumptively eligible for Medicaid. This allows temporary but immediate access to Medicaid coverage for certain eligible individuals and allows these individuals to get connected to more permanent coverage when the full Medicaid application is filed.

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QUALIFIED HOSPITALS

Qualified hospitals are allowed to make presumptive eligibility decisions prior to a formal determination of Medicaid eligibility by the Division of Medicaid (DOM).

A qualified hospital is one that participates as a Medicaid provider, Has filed a letter of intent to the Executive Director of DOM, Agrees to make HPE decisions according to state policies and procedures,

Has not been disqualified from making HPE decisions for failure to meet performance standards set by DOM.

HOSPITAL RESPONSIBILITIES

Hospital staff assigned to authorize HPE eligibility must make informed decisions using Medicaid policy & procedures addressed in this material to place time- limited Medicaid eligibility on file with DOM for certain children, pregnant women, parents or caretakers presumed to be eligible for Medicaid.

Participating hospitals may not delegate HPE decisions to non-hospital staff, such

as third party vendors or contractors.

Hospitals must:

Use the HPE Application Form provided by DOM to notify DOM of all PE approvals within 5 days of the HPE decision, as outlined below in the HPE Application Requirements.

Provide written notice to the individual assessed for HPE, as outlined below in the HPE Application Requirements. A model notice will be provided by DOM for your use.

Assist the individual in completing and submitting the full application for Medicaid before the end of the HPE period, as outlined below in the Application Requirements for Submitting Full Applications for HPE Approvals.

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DOM RESPONSIBILITIES The Division of Medicaid must:

e Provide the HPE application form and information on how to complete and submit the form to DOM,

e Provide training and certification to hospital staff assigned HPE responsibility,

e Develop training materials needed to train hospital staff assigned HPE responsibility, including the requirement for a passing score on a knowledge test prior to certifying a staff member to make HPE determinations.

e Provide oversight of program quality that includes:

>» Establishing performance standards that may require corrective action or disqualification of a hospital for failure to meet standards or follow state policies,

> Auditing hospital HPE approvals if necessary,

> Establishing procedures to ensure responsibilities for HPE determinations are fulfilled.

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PERFORMANCE STANDARDS

All hospitals newly electing HPE will be granted a 6-month implementation period during which time no performance standards will be imposed. This 6-month period begins after assigned hospital staff are trained and certified and begins submission of HPE decisions. During the implementation period, data will be collected by DOM regarding:

e The number of HPE approvals that have a full Medicaid application submitted before the end of the HPE period of eligibility, and,

e The number of HPE approvals that are determined to be Medicaid eligible based on submission of the full Medicaid application.

This data will be provided to the hospital on a monthly basis or more frequently if needed. DOM will monitor this data and provide feedback directly to the hospital staff certified to make HPE determinations in order to align the hospital with the expectations for the 2" 6-month period when a performance standard of 90% will be applied as follows:

e At least 90% of all HPE approvals submitted to DOM result in a full Medicaid application submitted before the end of the HPE period of eligibility. The number of full applications that are not submitted timely and the number of HPE approvals that are placed on file that do not result in a full application cannot exceed 10% of the total number of HPE approvals submitted to DOM during a month. Exceptions will be granted on a case by case basis, e.g., a HPE applicant dies or inpatient HPE applicant leaves the hospital on a week-end before the full application can be submitted. Although submission of a full Medicaid application is not a condition of eligibility for HPE, it is a performance standard established by the state to measure the extent to which individuals covered during a HPE period are encouraged and assisted by the hospital to submit a full application.

e At least 90% of HPE approvals are determined to be Medicaid eligible based on submission of the full Medicaid application. A full application that does not confirm Medicaid eligibility for the HPE period of eligibility cannot exceed 10% of the total number of HPE approvals processed during a

Page |S

month. An applicant’s failure to complete the full application process with DOM will not count against the hospital.

During the 2™ 6-month period, data collection and direct contact with the hospital will continue on a monthly or as-needed basis. No hospital will be disqualified during the 1 12 months of implementation of HPE. If the data collected during the first year of implementation suggests that a 90% accuracy rate for HPE decisions and/or timely submissions of full Medicaid applications for HPE approvals is not an achievable standard for a particular hospital, discussions will be held with hospital staff regarding corrective actions needed, any training needed and any possible alternate standard that could be applied if the 90% standard could not be met due to circumstances beyond the hospital’s control.

Effective with the 2™ year of participation in HPE, the performance standards shown above for submission of full Medicaid applications and the accuracy of the HPE decisions will increase and remain at 95%. The possibility of an alternate standard assigned for a pre-determined amount of time will be discussed as a corrective action measure if at any time a hospital falls below the 95% standard due to circumstances beyond their control. Feedback and direct contact with hospital staff will continue on an as-needed basis and data will be shared monthly regarding adherence to the performance standards.

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POPULATIONS ELIGIBLE FOR MEDICAID HPE

Under the ACA, coverage groups have been modified and income limits increased since there are no income deductions allowable under ACA budgeting rules. The groups covered and the new limits are outlined below. The limit is based on the household size of the budget group applicable to the individual applying for HPE, as explained in the HPE Determination Process section of this training.

1. Infants from birth up to age | — limit is 194% of the Federal Poverty Level (FPL).

2. Children age | up to age 6 — limit is 143% of the FPL, 3. Children age 6 up to age 19 — limit is 133% of the FPL,

4. Pregnant women — limit is 194% FPL. Pregnant minors (under age 19) can qualify regardless of household income.

5. Low Income Parent(s) or Caretaker Relative(s) of dependent child(ren) under age 18- limit is 24% FPL.

6. Former Foster Care Children — these are limited to foster children who were in the custody of the Department of Human Services (DHS) at age 18 and are currently under the age of 26 and are residents of MS. NOTE: In Mississippi, former foster children who aged-out of foster care at age 18 automatically received Medicaid to age 21 prior to the ACA. Effective with the ACA, the age limit for automatic eligibility was raised to age 26. Ifa HPE hospital identifies a former foster child who does not have Medicaid coverage who was in foster care in Mississippi and aged out of foster care in Mississippi at age 18, HPE is a possibility. DOM will verify the status of all such children with DHS before granting ongoing eligibility for Medicaid.

7. Certain Women with Breast & Cervical Cancer — women who are screened through the State Department of Health’s Breast & Cervical Cancer Early Detection Program and diagnosed with breast and/or cervical cancer must meet the following conditions for HPE coverage:

Page | 7

The woman must be under the age of 65,

Have no other creditable health coverage,

Have household income under 250% FPL,

Have been screened by a hospital that conducts screenings as a MS Breast and Cervical Cancer Program screening provider as authorized by the State Department of Health.

oo0oO0 oO

Children eligible for CHIP (Children’s Health Insurance Program) do not qualify for HPE.

The income limit based on household size for each covered group is found in the “MAGI Income Limits” handout #1.

The only allowable disregard of income is a 5% FPL disregard that is applied as needed to allow eligibility for Medicaid or CHIP. The income chart provided in this training material has the 5% allowable disregard built into the limits. When using the chart provided, the limits are the maximum allowable limits.

HPE is limited to no more than one period within two (2) calendar years. However, pregnant women are limited to one HPE period per pregnancy.

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ELIGIBILITY REQUIREMENTS

In order for an individual to be considered eligible for an HPE approval, the individual must be a child, a pregnant woman, a low-income parent or needy caretaker, a former foster child or a woman screened for breast and/or cervical cancer by a valid screening provider:

1. Income Requirements

e Children qualify on the basis of income & age. The MAGI household of a child applying for HPE must be equal to or less than the FPL applicable to their age group.

e Pregnant women age 19 & over must have MAGI household income equal to or less than 194% FPL. In addition, a pregnant woman’s MAGI household is increased by the number of babies expected. Pregnant minors, defined as under age 19, have MAGI household income disregarded for Medicaid purposes.

e Low-income parent(s) or needy caretakers qualify based on their relationship to a child under age 18 living in the home:

o A parent can be the natural, adoptive or stepparent of a child,

o A needy caretaker relative must meet the specified degree of relationship to at least one child under age 18 living in the household and must be the person with primary responsibility for the care of the child or children. The relationship must be that of a blood relative, including those of half-blood, and includes first cousins, nephews or nieces, and persons of preceding generations as denoted by prefixes of grand, great, or great-great; step-siblings; and, spouses of any person named above even after the marriage is terminated by death or divorce.

o The child(ren) under age 18 must be deprived of one or both parents because of incapacity, death or absence of a parent or the unemployment or under-employment of a 2-parent household. Deprivation allows the parent(s) or caretaker relative to qualify in combination with MAGI household

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income below the standard for the household size and meeting the degree of relationship.

e Former foster children who aged out of foster care in Mississippi at age 18 are not subject to an income limit in determining HPE provided the former foster child is over age 18.

e Breast & Cervical Cancer Program women are subject to a household limit of 250% FPL based on household size. NOTE: The MS State Department of Health is authorized to make a presumptive Medicaid eligibility decision for women who have been screened & diagnosed through their Breast & Cervical Cancer Program. As soon as the Health Department is notified of the cancer diagnosis by the screening provider, the case manager for the Breast & Cervical Cancer Program sends DOM the necessary information to immediately place eligibility on file for women determined presumptively eligible. An HPE decision may not be necessary since the State Department of Health is the lead agency for presumptive decisions for breast & cervical cancer patients.

2. Residency Requirement — the individual applying for HPE must be a resident of Mississippi. There is no requirement for a fixed address but the individual must be physically present in the state with the intent to reside.

3. Citizenship and/ or Satisfactory Immigration Status An individual applying for HPE must declare to be a U.S. citizen or an immigrant in the U.S in a satisfactory immigration status. Hospitals must rely on self-attested information from the immigrant. Check the listing below to determine if an immigrant can be eligible in Mississippi:

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Lawful Permanent Resident (LPR or Greencard holder) - who has been in the US. at least 5 years and has 40 Qualifying Quarters of Coverage with the Social Security Administration (SSA). A Qualifying Quarter means a quarter of coverage (3 calendar months ending March 31, June 30, September 30 or December 31) earned by the immigrant, a parent of an immigrant under age 18 and/or a spouse.

Asylee — can qualify for Medicaid until 7 years after the date of entry into the US.

Refugee — can qualify for Medicaid until 7 years after the date of entry into the US.

Cuban or Haitian entrant- can qualify for Medicaid until 7 years after the date of entry into the U.S.

Paroled into the U.S. — must have entered into U.S. before 08/22/1996 or have been in the U.S. at least 5 years and have 40 Qualifying Quarters of Coverage with SSA.

Conditional entrant granted before 1980 — must have 40 Qualifying Quarters of Coverage with SSA.

Battered spouse, child and parent- must have entered into U.S. before 08/22/1996 or have been in the U.S. at least 5 years and have 40 Qualifying Quarters of Coverage with SSA.

Victim of Trafficking and his/her spouse, child, sibling or parent- can qualify for Medicaid until 7 years after the date of entry into the U.S.

Member of a federally-recognized Indian tribe or American Indian Born in Canada — eligible for any Medicaid category if all other criteria met.

An individual who is lawfully residing in the U.S. and was receiving and eligible for Medicaid on 08/22/1996 is considered to be in a satisfactory status.

An honorably discharged veteran or individual on active duty in the U.S. military

or their spouse or their unmarried dependent child is considered to be in a satisfactory status.

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HPE APPLICATION REQUIREMENTS FOR HPE DECISIONS

. A one-page application for HPE decisions is used to transmit HPE approvals to the Division of Medicaid (DOM). Email or fax all HPE approvals:

e Email to Applications@medicaid.ms.gov, or, e Fax to 601-576- 4164

Prior to completing the HPE application, check the DOM web-portal to make sure the individual is not currently eligible and is not in need of HPE. In addition, ensure that there is no indication of HPE on file within the current or previous calendar year or for the current pregnancy.

. DOM will provide hospitals electing HPE with the HPE Application Form for duplication.

. An HPE approval must be transmitted to DOM within 5 days after the HPE approval decision is reached by the hospital. Basic identifying household information will be needed on the form.

. Ifthe form is not sent to DOM within 5 days of the date of the HPE decision, the HPE eligibility will not be placed on file using the outdated form. A new form with a new HPE decision date will be required.

. Hospitals must provide a written notice to all individuals assessed for HPE. The notice must provide the following information:

e If approved, the notice will provide the beginning and ending date of the HPE period and the Medicaid ID number (DOM will provide this information to the hospital), as described below in the HPE Period of Eligibility.

e If denied, the notice will give the reason for the denial and how to apply for full Medicaid.

e The notice must explain that HPE decisions may not be appealed. Only a formal Medicaid eligibility decision made by DOM grants appeal rights.

DOM will provide hospitals electing HPE with a model notice to use. Page | 12

6. DOM will assign a Medicaid ID number for the PE period of eligibility and notify the qualified hospital within 5 days of the Medicaid ID number assigned.

HPE PERIOD OF ELIGIBILITY

1. The begin date of the HPE eligibility period that will be entered on the HPE Application Form is the 1“ of the month in which the HPE decision is made. For example, if the hospital determines on January 15" that an individual is eligible for HPE, the begin date is January 1“. The hospital will have until January 20" to transmit the HPE Application Form to DOM but the begin date of the HPE period of eligibility is January 1°.

2. The end date of the HPE eligibility period is either:

e the last day of the month following the month the HPE period begins, or,

e ifa full application is submitted to DOM within the HPE period, the HPE period will be extended to the end of the month in which DOM makes the final eligibility decision.

Example: The HPE begin date is January 1". The initial end date will be the last day of February. Ifa full application is received by DOM before the last day of February, the PE period will be extended to the last day of the month in which DOM makes the decision regarding eligibility. If DOM makes a decision on March 2™ regarding eligibility, the PE period for Medicaid eligibility will be extended to the last day of March regardless of the outcome of the full application.

Page | 13

3. DOM will be reviewing the full application for all household members applying. The full application will be evaluated for Medicaid, CHIP and possible transfer to the federal healthcare marketplace for insurance coverage. A prior HPE approval will be valid regardless of the final outcome of the full Medicaid application.

For example, if a child with a HPE period of January 1**— March 31 is determined to be CHIP eligible, the child’s CHIP eligibility cannot begin until April 1". If the same child is determined to be Medicaid eligible rather than CHIP, Medicaid coverage will be possible for April forward plus up to 3 months prior to the month the full application is received by DOM if retroactive coverage is requested. In this example, if the full application was received in February and January Medicaid eligibility is already on file (HPE eligibility), the retro period possible is November and December. If the child is determined ineligible for Medicaid or CHIP, the Medicaid coverage ends March 31" and the account is transferred to the marketplace for evaluation of health insurance coverage through the marketplace.

MEDICAID COVERED BENEFITS FOR HPE APPROVALS

Covered benefits include all covered Medicaid benefits as those provided under the Medicaid group for which the individual is determined presumptively eligible.

The exception to full coverage is for pregnant women. Benefits for

pregnant women under HPE are limited to ambulatory prenatal care. Birthing expenses are not covered under HPE.

Page | 14

APPLICATION REQUIREMENTS FOR SUBMITTING FULL APPLICATIONS FOR HPE APPROVALS

1. The ACA requires the use of a single, streamlined application for all “insurance affordability programs” which includes Medicaid and CHIP through DOM and advance payment of premium tax credits and cost-sharing subsidies through DOM’s affiliation with the federal healthcare marketplace. When qualified hospitals submit the full application following HPE approvals, the application will be evaluated for Medicaid, CHIP and insurance through the federal healthcare marketplace.

2. In addition to the use of the single application, the ACA requires that applications be accepted: e On-line by going to the DOM website at www.medicaid.ms.gov,

e By telephone (a signature will be recorded),

e Via mail,

e Inperson, and

e Through other commonly available electronic means (such as faxing and/or emailing). Full applications may be faxed or emailed to the same email address or fax number provided for the HPE approvals.

3. In-person interviews for MAGI-based applications are prohibited under the ACA; however, individuals may apply in person if they choose to do so.

4. The full application is available on line at www.medicaid.ms.gov

Page | 15

THE HPE DETERMINATION PROCESS Complete the HPE Application Form

The starting point for determining HPE is for a hospital staff person trained and certified in HPE to discuss the information needed on the HPE Application Form with the HPE applicant. A separate form is filled out for each HH member that needs to apply for HPE. The key to HPE is to determine each individual’s:

e Age

e Relationship to other HH members

e Tax status

e Household income & who receives the income

The application form asks about U.S. citizenship and immigration information (if not a U.S. citizen). There is no requirement to verify citizenship or immigration status for HPE purposes; rely on self-attestation from the applicant(s) but the individual must attest to being a citizen or immigrant in the U.S. in a satisfactory immigration status using the list of statuses provided in this material.

Construct a MAGI Household (HH) for Each Applicant

Use the chart entitled “Construct a MAGI HH for Each Applicant” (Handout #1) to determine if each individual applying is:

e A tax filer

e A tax dependent or a tax dependent who meets an exception,

e An individual who is both a tax filer and a tax dependent (including exceptions), in which case use tax dependent rules to construct a MAGI HH,

e Anon-filer, meaning the individual either does not expect to file taxes and is not claimed as a tax dependent OR is a tax dependent who meets an exception.

Page | 16

Use the “Tax Filer & Non-Tax Filer Chart” (Handout #2) as an added resource for use in determining household composition. Handouts #1 and #2 are designed to help determine which household members must be considered a “household” for budgeting purposes and whose income must count toward the income limit for the household size.

Income Counting Rules

Refer to the “Income Counting Rules” (Handout #3) for the types of income that do not count and income that does count and how to arrive at countable income if viewing a federal tax return.

Refer to the “Calculating MAGI HH Income” (Handout #4) and the “Required to File Rule for Counting the Income of a Tax Dependent or Non-Filer Child” (Handout #5) for further resources on determining whose income counts within the household composition.

Combine the income that counts for each person in a “household” and compare the total income to the “MAGI Income Limits” chart (Handout #6) applicable to the household constructed. If total income is equal to or less than the limit, the individual is eligible for HPE. Keep in mind that the income limits shown on this chart contain the allowable 5% FPL disregard so the limits shown are the maximum allowable for use with HPE.

Page | 17

Examples

Filer Example 1 : HH consists of married parents Bob & Mary who have one common child, Ben (age 15) and Jane (age 22) who is Mary’s child (Bob’s stepchild). Bob is a tax filer and has a spouse, Mary. He claims Ben and Jane as dependents.

e Tax filer rules apply to each HH member. No exceptions exist in this HH.

e HH size is 4 for each member.

e Income of Bob & Mary would count. Income of Ben & Jane would count only if “required to file.”

Filer Example 2: Same example as above but 22 year old Jane is married to Jack. Jane and Jack live separately from Bob/Mary but Bob still claims Jane as a tax dependent.

e Tax filer rules continue to apply for Bob, Mary, Ben

e HH size for Bob, Mary and Ben remains 4. Bob & Mary’s income counts to all 4.

e Jane’s HH size is 5 because she is a married tax dependent; her HH includes the tax filer’s HH Bob, Mary, Ben, herself and her spouse, Jack. Income for Jane would include Bob & Mary’s income as well as Jack’s income, if any.

e Jack is not claimed as a tax dependent so his HH consists of him and his spouse (HH of 2). Income that counts would be Jack & Jane’s income, if any.

Page | 18

Exceptions to Tax Filer Rules: if a tax dependent is not the tax filer’s spouse or child, or if the tax dependent is under age 19 and lives parents (married or unmarried) who will not file jointly, or if the tax dependent is claimed as a tax dependent by a non-custodial parent then the tax dependent meets an exception and is treated as a non-filer.

Filer Exception Example 1: Sue and Bill are unmarried parents of Betty (15). Jenny (18) is Sue’s child. Bill is a tax filer and claims Sue, Betty and Jenny as tax dependents.

Bill is a tax filer so his HH is 4. Income of all 4 counts, unless Betty & Jenny are not “required to file.”

Sue is not the spouse of Bill so she is treated as an exception. Sue’s HH is herself and her children living with her, Betty and Jenny (HH of 3). Sue’s income would count, if any & Betty & Jenny’s income would count if “required to file.”

Betty is an exception because she is living with parents who are not married & cannot file jointly. Betty’s HH size is 4 (child & parents/siblings living together). Parental income counts as well as income of Betty & Jenny if “required to file.”

Jenny is an exception because she is a tax dependent who is not the tax filer’s child (Bill is not her father). Her HH size is 3 (self + parent/sibling living together). Her income would be her mother’s income. If Jenny & Betty are “required to file” then their income would count in Jenny’s budget.

Filer Exception Example 2: Same example as above but Bill and Sue file taxes separately. Bill claims Betty and Sue claims Jenny as their respective tax dependents.

Bill’s HH size is 2 (self + 1 dependent). Bill’s income counts + Betty’s income only if “required to file.”

Sue’s HH size is 2 (self + 1 dependent). Sue’s income counts + Jenny’s only if “required to file.”

Page | 19

e Betty is an exception because she is living with unmarried parents so her HH size is 4 (self + parents/sibling). Parental income counts. Betty & Jenny’s income would count only if “required to file.”

e Jenny is not an exception. Her situation follows tax filer rules. She is the dependent of her mother so her HH size is 2. Mother’s income counts and Jenny’s only if “required to file.”

Non-Filer Rules: the non-filer rules include the rule for an adult and child:

e A non-filer adult’s household includes the non-filer, his/her spouse (if any) and his/her children living together. Income of a child not required to file a tax return does not count. A parent cannot be separated from his/her child if living together so the parent’s income always counts toward a child.

e A non-filer child’s household includes the non-filer, his/her parent(s) and siblings living together.

Non-filer Example 1: Gerald and Monica are married but neither files taxes. Bryan is their common child, John belongs to Mary. All 4 live together. The HH size for each HH member is 4 because parents and their children compose the HH. Parental income counts. The children’s income counts only if “required to file.”

Non-filer Example 2: Gerald and Monica are unmarried and do not file taxes. Bryan and John are their children.

e Gerald’s HH size is 3 (parent/children living together). Parent’s income counts & children’s income counts only if “required to file,”

e Monica’s HH size is 3 (parent/children living together). Parent’s income counts & children’s income counts only if “required to file,”

e Bryan and John’s HH size is both 4 (parents and children living together). Parental income counts and Bryan & John’s income counts only if “required to file.”

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(Hospital Letterhead) Application for Hospital Presumptive Eligibility Results

(Date)

Dear

You were evaluated for Hospital Presumptive Eligibility (HPE) which provides temporary Medicaid benefits. The outcome is:

Q) You are approved. Your Medicaid begin date is:

The end date of this temporary period is

Your Medicaid ID # is

You must complete a full Medicaid application in order for Medicaid to continue.

Q) According to our records, we assisted you in completing this full application on . You will be notified of the outcome by the Division of Medicaid.

Q) According to our records, we were not able to assist you in completing a full Medicaid application. If you want to apply, contact the Division of Medicaid at www.medicaid.ms.gov or call 1-800-421-2408 to get information on how to apply.

Q You are denied HPE. The reason for the denial is: (1) ~The household has too much income to qualify.

OQ) ‘There is no HPE Medicaid coverage group available to assist you.

Q) = Other

Hospital Staff Member Name Contact Information

HPE APPLICATION FORM

Qualified Hospital Date of HPE Decision

Full Name of HPE Individual

SSN of Individual (Optional) Sex: O Female (1 Male DOB:

U.S. Citizen? QYes (No ‘If nota U.S. citizen, is immigration status satisfactory? U1 Yes Q No Resident of MS? O) Yes QO. No

Was HPE Applicant in Foster Care at Age 18? 0) Yes (1) No If yes, in what state?

Full Address of HPE Individual (Street)

City State Zip Code

Mailing Address (if different) (street or PO Box)

City State Zip Code Phone Number(s) (C) (H) (W) Individual Qualifies As: (I) Pregnant Woman Qi Child Under Age 19 Q Parent of Dependent Child < 18

QO Caretaker of Dependent Child<18 © Former Foster Care Child OQ) Woman screened & diagnosed through the Breast & Cervical Cancer Program (screening hospitals only)

Tax Status of Individual: 1 Filer Household QO) Non-Filer Household Number in Household Household Income S

Name of Household Members (other than HPE Age Relationship to HPE Applicant Applicant

HPE APPLICATION FORM

Comments:

Name of Certified Hospital Staff Member Completing This Form Contact Number

For Use by Division of Medicaid: HPE Medicaid ID# Assigned

Begin Date End Date

Medicaid Specialist Phone #

Date

HPE APPLICATION FORM INSTRUCTIONS

The HPE Application Form is designed to be completed by a HPE hospital staff member certified in HPE after obtaining household information from the HPE applicant. This form is not designed to be completed by the HPE applicant.

Qualified Hospital — please give the full name of the hospital submitting the HPE Application Form.

Date of HPE Decision — enter the date the hospital made the decision regarding HPE for the individual applying. This is the date that starts the 5-day clock for submission of the HPE approval to DOM.

Full Name of HPE Individual — enter the first, middle & last name of the person applying for HPE.

SSN of Individual (Optional) — it is optional to furnish SSN’s for an individual applying for HPE but in order for DOM to prevent duplicate ID numbers from being issued for the same person and in order for DOM to match up HPE eligible recipients with the subsequent submission of a full application, SSN’s are helpful.

Sex — check female or male. Date of Birth — enter the date of birth for the individual applying for HPE. U.S. Citizen? — enter if the individual has declared to be a U.S. citizen.

If not a U.S. citizen, is immigration status satisfactory? — enter whether the non-citizen applicant for HPE has declared to be ina satisfactory immigration status, meaning the individual has in his/her possession a green card or other papers that would show that he/she entered the U.S. legally. See the list in the training material for definitions of the various types of immigration statuses.

Resident of MS — enter whether the individual declares to be a resident of MS.

Was HPE applicant in Foster Care at Age 18? - ask if the individual was in foster care in Mississippi and aged out at age 18. Only individuals in foster care at age 18 in Mississippi qualify for continued Medicaid coverage provided the individual is under age 26.

Full Address of HPE Individual — enter the street address of the individual applying for PE. Mailing Address - enter only if the mailing address is different from the street address.

Phone Number(s) — enter cell, home and work phone numbers if appropriate. If not, enter a contact number if available.

HPE APPLICATION FORM INSTRUCTIONS

Individual Applying Qualifies As: check the appropriate block to indicate the basis for the HPE eligibility.

Tax Status of Individual - enter whether the HPE individual is a tax filer or a non-filer. A non-filer either does not file federal taxes or

is someone who meets an exception to tax filer rules as described in training material.

Number in Household — enter the number of household members included in the HPE individual’s household that was used as the basis for the HPE decision.

Household Income — enter the household income that was used to determine the HPE individual’s eligibility.

Household Members — enter the names of the household members used in the budget for the HPE individual. There are 7 spaces provided on the form to add household members in addition to the HPE applicant. If additional household members need to be named, use a separate sheet of paper to attach to the form.

NOTE: Use a separate form for each person within a household applying for HPE. If more than 8 household members are present, use additional pages to list the names of the household members or include the needed information in the “comments” section.

Comments — the hospital staff person completing this form will use this space to record any necessary comments about the household or the HPE application.

Name of Certified Hospital Staff Member Completing the Form — the authorized hospital staff person will enter his/her name and contact information in the event the DOM staff person needs to make contact about information on the form.

For Use by Division of Medicaid: DOM will return the form with the Medicaid ID assigned to the PE period and the beginning and ending dates assigned to the PE period. The Medicaid Specialist entering the HPE period will enter their identifying and contact information.

“REQUIRED TO FILE” RULE FOR COUNTING THE INCOME OF A TAX DEPENDENT OR NON-FILER CHILD (Handout #5)

Tax Filer rules require income of a tax dependent to count only if the dependent is “required to file.”

Non-Filer rules require the income of a child under age 19 to count only if the child is “required to file.”

“Required to file” is different from “filing” — Many dependents and children who work and pay taxes file a tax return in order to get a refund. However, the person may not be “required” to file a tax return.

In order to determine if a tax dependent or non-filer child is “required to file” a federal tax return for Medicaid & CHIP purposes, follow these steps:

1. The MAGI application form asks the question “does this person plan to file a federal income tax return next year?”

QO) No -If checked, accept this response — do not determine if “required to file”

Q) Yes —If checked, determine if the person is “required to file” in Step 2.

2. Determine “taxable” income of the tax dependent or non-filer child.

e Do not include Social Security (SS) or Railroad Retirement Benefits (RRB) received by the tax dependent or non-filer child. If the only income received by a tax dependent or non-filer child is SS or RRB, the benefits are generally not taxable.

e If there is income other than or in addition to SS or RRB, these

benefits may be taxable. Calculate the total “other” income per dependent or non-filer child and go to Step 3.

3. Compare taxable income to the following tax dependent filing requirement limits published by the IRS keeping in mind the following:

e Test Earned and Unearned income separately against the appropriate limit.

e Do not include SS or RRB against the unearned income limit but include any other type of countable unearned income.

e Use IRS filing limits for earned/unearned income in effect at the time of the eligibility decision or the most recent limits available from IRS at the time of the decision.

Single or Married Dependent Under Age 65 — 2013 Limits

Unearned Income_ | More than $1,000

Earned Income More than $6,100

Single Dependent Age 65 or Over or Blind — 2013 Limits

Unearned Income_| More than $2,500 ($4,000 if age 65 or older and blind)

Earned Income More than $7,600 ($9,100 if age 65 or older and blind) |

Married Dependent Age 65 or Over or Blind — 2013 Limits

Unearned Income _| More than $2,200 ($3,400 if age 65 or older and blind)

Earned Income More than $7,300 ($8,500 if age 65 or older and blind)

4. If taxable earned income and/or taxable unearned income computed for Step 3 exceeds the limit appropriate for the tax dependent or non-filer child, the income (other than the SS or RRB excluded in this process) counts in the budget group of the tax dependent or non-filer child because the individual is “required to file.”

If income is below the limit, the individual is not required to file and the individual’s income does not count.

2|Page

TAX FILER & NON-TAX FILER RULES CHART

(Handout #2)

TAX FILER HOUSEHOLD RULES

Applicant Tax filer Status + Filing Household Qualifier Income Is: Thresholds (2013) Composition

Married Filing Jointly (MFJ) | Tax filer + all | MFJ Spouses are considered 1 Household. | Income that counts is total countable MAGI

dependents income for the Household (HH). Do not count

Both spouses < 65 $20,000 claimed income of tax dependent that is not required

1 spouse > 65 $21,200 .

Both spouses >65 $22,400 to file a tax return, regardless whether dependent | files. If required to file, dependent’s income counts for HH.

Tax Filer Married Filing Separately Tax filer + all | Spouses filing separately are included in Same as above for spouses living together. dependents each other’s tax HH if living together;

Any age $3,900 spouses living apart are 2 separate HH’s.

Tax Filer Head of Household Tax filer + all | Limited to single, divorced or otherwise Same as above <65 $12,850 dependents unmarried w/ qualifying dependents in HH

>65 $14,350

Tax Filer Qualifying Widow(er) Tax filer + all | Must have at least 1 dependent Same as above <65 $16,100 dependents >65 $17,300 Tax Filer Single Tax filer + Unmarried, can have dependent but Same as above

<65 $10,000 dependents, | would usually file as HOH if claiming a

>65 $11,500 if any dependent Tax Child (biological, adopted, HH issameas | Note: Married couples living together HH income is that of the Tax filer’s HH. Dependent | step) Tax filer’s HH | must be included with each other.

Other Individuals (Family or non-related individuals who meet requirements to be

claimed as a tax dependent)

See “Required to File Rule for Counting the Income of a Tax Dependent or Non-Filer Child”

TAX FILER & NON-TAX FILER RULES CHART (Handout #2)

EXCEPTIONS TO USING TAX FILER HOUSEHOLD RULES:

e Tax dependent is not the Tax

ler’s spouse (unmarried couple

ing together, tax filer’s parent, etc.)

e Tax dependent is not the Tax filer’s child (foster child, related or unrelated child dependent)

e Tax dependent under age 19 lives with 2 parents (married or unmarried) who do not plan to file jointly e Tax dependent under age 19 is claimed by a non-custodial parent

Treat as Non-filer Treat as Non-filer Treat as Non-filer Treat as Non-filer

NON-FILER HOUSEHOLD RULES

Applicant Is:

HH Composition

Qualifier

HH Income

Adult Non-

ler

HH includes non-filer adult, spouse & children living in the home

The MAGI income of a parent always counts for their child.

See “Calculating MAGI HH Income”

Income of all HH members except income of a child who is not required to file a tax return is not counted as HH income.

Child Non-Filer (Under Age 19)

HH includes non-filer child + parent(s) and sibling(s) under age 19 living together

Same as above

Table of Contents

State/Territory Name: Mississippi State Plan Amendment (SPA) #:14-0024 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 26, 2015

Dr. David J. Dzielak Executive Director Mississippi Division of Medicaid 550 High Street, Suite 1000 Jackson, Mississippi 39201-1399

Attention: Margaret Wilson

RE: Title XIX State Plan Amendment, MS 14-0024

Dear Dr. Dzielak:

We have reviewed the proposed Mississippi state plan amendment 14-0024, which was submitted to the Atlanta Regional Office on December 23, 2014. The SPA increases the percentage of Medicaid enrollees, adds additional categories of eligibility, and requires mandatory participation in Mississippi Coordinated Access Network (MSCAN) for certain Medicaid beneficiaries.

Based on the information provided, the Medicaid State Plan Amendment 14-0024 was approved on February 26, 2015. The effective date of this amendment is December 1, 2014. We are enclosing the approved HCFA-179 and the plan pages.

If you have any additional questions or need further assistance, please contact Tandra Hodges at (404) 562-7409 or Tandra.Hodges@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 1. TRANSMITTAL NUMBER: 14-024 2. STATE MS 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE 12/01/2014 5. TYPE OF PLAN MATERIAL (Check One):

NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: SSA § 1932(a)(1)(A); 42 CFR § 438.50. 7. FEDERAL BUDGET IMPACT: FY 2014: $0.00

FY 2015: $0.00

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 3.1 F, Pages 1-16

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

Attachment 3.1 F, Page 1-16 10. SUBJECT OF AMENDMENT: Mississippi Medicaid State Plan Amendment (SPA) 14-024 Mississippi Coordinated Access Network (MSCAN) proposes changes to include (1) increasing the percentage of Medicaid enrollees, (2) adding additional categories of eligibility, and (3) requiring mandatory participation in MSCAN for certain Medicaid beneficiaries, effective December 1, 2014. 11. GOVERNOR’S REVIEW (Check One):

GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED:

COMMENTS OF GOVERNOR’S OFFICE ENCLOSED

NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: /s/ 16. RETURN TO:

David J. Dzielak Miss. Division of Medicaid Attn: Margaret Wilson 550 High Street, Suite 1000 Jackson, MS 39201-1399

13. TYPED NAME: David J. Dzielak 14. TITLE: Executive Director 15. DATE SUBMITTED: DEC 23, 2014 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 12-23-14

18. DATE APPROVED: 02-26-15 PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 12-01-14

20. SIGNATURE OF REGIONAL OFFICIAL: //s// 21. TYPED NAME: Jackie Glaze

22. TITLE: Associate Regional Administrator Division of Medicaid & Children Health Opns

23. REMARKS:

CMS-PM-10120

ATTACHMENT 3.1-F Date: January 25, 2005

Page 1 OMB No.:0938-933 State: Mississippi ______________________________________________________________________________________________

Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014

1932(a)(1)(A)

A. Section 1932(a)(1)(A) of the Social Security Act.

The State requires mandatory enrollment of certain Medicaid beneficiaries and voluntary enrollment of federally mandated Medicaid beneficiaries into coordinated care organizations (CCOs) in the absence of section 1115 or section 1915(b) waiver authority. This authority is granted under section 1932(a)(1)(A) of the Social Security Act (the Act). Under this authority, a state can amend its Medicaid state plan to enroll certain categories of Medicaid beneficiaries in managed care entities without being out of compliance with provisions of section 1902 of the Act on statewideness (42 CFR § 431.50), freedom of choice (42 CFR § 431.51) or comparability (42 CFR § 440.230). This authority may not be used to mandate enrollment in Prepaid Inpatient Health Plans (PIHPs), Prepaid Ambulatory Health Plans (PAHPs), nor can it be used to mandate the enrollment of Medicaid beneficiaries who are Medicare eligible, who are Indians (unless they would be enrolled in certain plans—see D.2.ii. below), or who meet certain categories of “special needs” beneficiaries (see D.2.iii. - vi. below).

B. General Description of the Program and Public Process.

1932(a)(1)(B)(i)

1. The State will contract with an 1932(a)(1)(B)(ii) 42 CFR § 438.50(b)(1)

X i. MCO

____ ii. PCCM (including capitated PCCMs that qualify as PAHPs)

____ iii. Both

42 CFR § 438.50(b)(2)

2. The payment method to the contracting entity will be: 42 CFR § 438.50(b)(3)

____ i. fee for service;

X ii. capitation;

____iii. a case management fee;

____iv. a bonus/incentive payment;

____ v. a supplemental payment, or

____vi. other. (Please provide a description below).

CMS-PM-10120

ATTACHMENT 3.1-F Date: January 25, 2005

Page 2 OMB No.:0938-933 State: Mississippi ______________________________________________________________________________________________

Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014 To meet the goals of beneficiary choice, financial stability of the program and administrative ease, no more than three (3) and no less than two (2) CCOs are awarded a contract to administer a care coordination program. The program is statewide with both voluntary and mandatory enrollment depending on the beneficiary’s category of eligibility. Medicaid beneficiaries excluded from the program regardless of the category of eligibility are listed in B.5.

CCOs are defined as organizations that meet the requirements for participation as a contractor in the Mississippi Coordinated Access Network (MississippiCAN) program and that manage the purchase and provision of health care services to MississippiCAN enrollees.

Contracted CCOs are selected through a competitive Request for Proposals process.

CCOs are required to:

 Demonstrate information systems are in place to meet all of the operating and reporting requirements of the program, including the collection of third party liability payments;  Operate both member and provider call centers. The member call center must be available to members twenty-four (24) hours a day, seven (7) days a week. The provider call center must operate during normal providers’ business hours;  Process claims in compliance with established minimum standards for financial and administrative accuracy and timeliness of processing with standards being no less than current Medicaid fee-for-service standards;  Submit complete encounter data that meets federal requirements and allows DOM to monitor the program. CCOs that do not meet standards will be penalized.

CCOs are required to provide a comprehensive package of services that include, at a minimum, the current Mississippi Medicaid benefits. CCOs are not responsible for inpatient hospital services. CCOs are required to:

 Participate as partners with providers and beneficiaries to arrange delivery of quality, cost-effective health care services, with medical homes and comprehensive care management programs to improve health outcomes.  Ensure annual wellness physical exams to establish a baseline, to measure change and to coordinate care appropriately by developing a health and wellness plan with interventions identified to improve outcomes.

CMS-PM-10120

ATTACHMENT 3.1-F Date: January 25, 2005

Page 3 OMB No.:0938-933 State: Mississippi ______________________________________________________________________________________________

Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014  Develop disease management programs for chronic or very high cost conditions including, but not limited to diabetes, asthma, hypertension, obesity, congestive heart disease, organ transplants, and improved birth outcomes with a comprehensive health education program to support disease management.  Establish quality assurance programs to assess actual performance and ensure that members receive medically appropriate care on a timely basis with positive or improved outcomes, access to effective complaint resolution and grievance processes and support for electronic medical records in provider offices to promote efficient coordinated care with improved outcomes.

1905(t)

3. For states that pay a PCCM on a fee-for-service basis, incentive 42 CFR § 438.6(c)(5)(iii)(iv)

case management fee, if certain conditions are met.

If applicable to this state plan, place a check mark to affirm the state has met all of the following conditions (which are identical to the risk incentive rules for managed care contracts published in 42 CFR § 438.6(c)(5)(iv)).

____i. Incentive payments to the PCCM will not exceed 5% of the total FFS payments for those services provided or authorized by the PCCM for the period covered.

____ii. Incentives will be based upon specific activities and targets.

____iii. Incentives will be based upon a fixed period of time.

____iv. Incentives will not be renewed automatically.

____v. Incentives will be made available to both public and private PCCMs.

____vi. Incentives will not be conditioned on intergovernmental transfer agreements.

X vii. Not applicable to this 1932 state plan amendment.

42 CFR § 438.50(b)(4) 4. Describe the public process utilized for both the design of the program and its initial implementation. In addition, describe what methods the state will use to ensure ongoing public involvement once the state plan program has been implemented. (Example: public meeting, advisory groups.)

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ATTACHMENT 3.1-F Date: January 25, 2005

Page 4 OMB No.:0938-933 State: Mississippi ______________________________________________________________________________________________

Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014

The MississippiCAN program was authorized in 2010, with an effective date of 1/1/2011, through State legislation in accordance with Miss. Code Ann. Section 43-13-117(H). The Division of Medicaid initially issued a public notice requesting input on a proposed care coordination program. The public notice was e-mailed to various provider associations and advocacy groups in addition to posting it on the agency website seeking comments/revisions/input.

The agency also met with Mississippi legislative leaders and two (2) public hearings were held at the State Capitol to allow for a presentation of the proposed program by agency staff. Various providers, advocacy organizations and many legislators provided input at these hearings. The Governor also called a meeting with various provider groups to discuss the program, seek input, and answer any questions.

The initial program design summary, request for proposal (RFP) and responses to frequently asked questions were posted and updated on the State’s website prior to the implementation of the program.

The State will continue to utilize every opportunity to talk with the various stakeholders such as consumers, providers, advocates, etc. At a minimum the State will meet with stakeholders two (2) times a year.

The Division of Medicaid will request comments on proposed changes to the MississippiCAN program by issuing a public notice(s) via e-mail to various provider associations and advocacy groups in addition to posting it on the agency’s’ website.

1932(a)(1)(A) 5. The State requires mandatory and allows voluntary enrollment depending on the beneficiary’s code of eligibility into the MississippiCAN program on a statewide basis.

See Section D for Eligibility Groups.

Enrollment limit increased to the greater of:

1. Forty-five percent (45%) of the total enrollment of all Mississippi Medicaid beneficiaries; or

2. The total of eligible beneficiaries enrolled in MSCAN as of January 1, 2014, plus the categories of beneficiaries composed primarily of persons younger than nineteen (19) years of age.

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Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014

Medicaid beneficiaries excluded from the program regardless of the category of eligibility include persons:

• In an institution such as a nursing facility, intermediate care facility for individuals with intellectual disabilities (ICF/IID) or psychiatric residential treatment facility (PRTF), • Eligible for Medicare, • Locked-in any Medicaid waiver program, and • With hemophilia.

All beneficiaries have freedom of choice in selecting the CCO. All beneficiaries initially enrolled in a CCO are allowed to change CCOs “without cause” during the first ninety (90) days of the initial enrollment effective for the first year. After the first year of enrollment in a CCO all beneficiaries are allowed to enroll in a different CCO during the Medicaid annual open enrollment period October 1 through December 15.

Beneficiaries exempt from mandatory enrollment may disenroll during the first ninety (90) days following their initial enrollment in a CCO. After the first year of enrollment, beneficiaries exempt from mandatory enrollment may disenroll during the Medicaid annual open enrollment period October 1 through December 15.

Refer to Section J.4. for disenrollment “with cause”.

C. State Assurances and Compliance with Statutes and Regulations

If applicable to the state plan, place a check mark to affirm that compliance with the following statutes and regulations will be met.

1932(a)(1)(A)(i)(I) 1. X The state assures that all of the applicable requirements of 1903(m)

section 1903(m) of the Act, for MCOs and MCO contracts will be met. 42 CFR § 438.50(c)(1)

1932(a)(1)(A)(i)(I) 2. ____The state assures that all the applicable requirements of section 1905(t) 1905(t) of the Act for PCCMs and PCCM contracts will be met. 42 CFR § 438.50(c)(2) 1902(a)(23)(A)

1932(a)(1)(A)

3. X The state assures that all the applicable requirements of section 1932

CMS-PM-10120

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Page 6 OMB No.:0938-933 State: Mississippi ______________________________________________________________________________________________

Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014 42 CFR § 438.50(c)(3) (including subpart (a)(1)(A)) of the Act, for the state's option to limit freedom of choice by requiring recipients to receive their benefits through managed care entities will be met.

1932(a)(1)(A 4. X The state assures that all the applicable requirements of 42 CFR § 431.51 42 CFR § 431.51 regarding freedom of choice for family planning services and supplies as 1905(a)(4)(C) defined in section 1905(a)(4)(C) will be met.

1932(a)(1)(A)

5. X The state assures that all applicable managed care requirements of 42 CFR Part 438

42 CFR § Part 438 for MCOs and PCCMs will be met. 42 CFR § 438.50(c)(4)

1903(m)

1932(a)(1)(A)

6. X The state assures that all applicable requirements of 42 CFR § 438.6(c) 42 CFR § 438.6(c)

for payments under any risk contracts will be met. 42 CFR § 438.50(c)(6)

1932(a)(1)(A)

7. ____ The state assures that all applicable requirements of 42 CFR § 447.362 for 42 CFR § 447.362

payments under any non-risk contracts will be met. 42 CFR § 438.50(c)(6)

45 CFR § 74.40 8. X The state assures that all applicable requirements of 45 CFR § 92.36 for procurement of contracts will be met.

D. Eligible groups

1932(a)(1)(A)(i)

1. List all eligible groups that will be enrolled on a mandatory basis.

• Supplemental Security Income - 1902(a)(10)(A)(i)(II); Only beneficiaries age 19 to 65 in the eligibility category of low income and age 65 or older, blind, or disabled receiving SSI cash assistance or “deemed” to be cash recipients.

• Working disabled – 1902(a)(10)(A)(ii)(XIII); Beneficiaries age 19 or older and disabled who work with earnings under 250% of FPL and unearned income under 135% of FPL with a resource limit of $24,000/$26,000. A premium is required in certain cases.

• Breast/Cervical Cancer Group - 1902(a)(10)(A)(ii)(XVIII). Female beneficiaries ages 19 to 65 whose income level is 250% of FPL with no other health insurance who have been screened and diagnosed with breast or cervical cancer under the CDC’s screening program

CMS-PM-10120

ATTACHMENT 3.1-F Date: January 25, 2005

Page 7 OMB No.:0938-933 State: Mississippi ______________________________________________________________________________________________

Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014 administered by the MS State Dept. of Health.

• Pregnant Women Pregnant women, age 8 to 65, whose family income does not exceed 194% of FPL for the appropriate family size which includes the pregnant women, her spouse and children, if applicable, and unborn(s). A pregnant woman’s eligibility includes a two (2)-month postpartum period following the month of delivery, miscarriage or other termination of pregnancy.

• Infants up to age 1 Infants up to age 1 whose family income does not exceed 194% of FPL for the appropriate family size. Infants born from a Medicaid eligible mother automatically receive benefits for one subsequent year.

• Parents and Caretaker Relatives with Dependent Children under age 18 Adults age 19 to 65. As a condition of eligibility, the adult must cooperate with child support enforcement requirements for each eligible child deprived due to a parent’s continued absence from the home.

• Children age 1 up to 6 Children age 1 up to 6 whose family income does not exceed 143% of FPL.

• Children age 6 up to 19 Children age 6 up to 19 whose family income does not exceed 107% of FPL.

• Quasi-CHIP Children Children age 6 up to 19 whose family income is between 107% - 133% of FPL. These children would have previously qualified for CHIP under the pre-ACA MAGI rules.

2. Mandatory exempt groups identified in 1932(a)(1)(A)(i) and 42 CFR § 438.50.

Use a check mark to affirm whether there is voluntary enrollment of any of the following mandatory exempt groups.

1932(a)(2)(B)

i. ____Recipients who are also eligible for Medicare. 42 CFR § 438.50(d)(1)

If enrollment is voluntary, describe the circumstances of enrollment. (Example: Recipients who become Medicare eligible during mid- enrollment, remain eligible for managed care and are not disenrolled into fee-for-service.)

CMS-PM-10120

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Page 8 OMB No.:0938-933 State: Mississippi ______________________________________________________________________________________________

Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014

1932(a)(2)(C)

ii. X Indians who are members of Federally recognized Tribes except when 42 CFR § 438.50(d)(2) the MCO or PCCM is operated by the Indian Health Service or an Indian Health program operating under a contract, grant or cooperative agreement with the Indian Health Service pursuant to the Indian Self Determination Act; or an Urban Indian program operating under a contract or grant with the Indian Health Service pursuant to title V of the Indian Health Care Improvement Act.

1932(a)(2)(A)(i)

iii. X Children under the age of 19 years, who are eligible for Supplemental 42 CFR § 438.50(d)(3)(i)

Security Income (SSI) under title XVI.

1932(a)(2)(A)(iii)

iv. X Children under the age of 19 years who are eligible under Section 42 CFR § 438.50(d)(3)(ii)

1902(e)(3) of the Act.

1932(a)(2)(A)(v)

v. X Children under the age of 19 years who are in foster care or other out- 42 CFR § 438.50(3)(iii) of-the-home placement.

1932(a)(2)(A)(iv)

vi. X Children under the age of 19 years who are receiving foster care or 42 CFR § 438.50(3)(iv)

adoption assistance under title IV-E.

1932(a)(2)(A)(ii)

vii. ___ Children under the age of 19 years who are receiving services through a 42 CFR § 438.50(3)(v) family-centered, community based, coordinated care system that

receives grant funds under section 501(a)(1)(D) of title V, and is

defined by the state in terms of either program participation or special

health care needs.

E. Identification of Mandatory Exempt Groups

1932(a)(2) 1. Describe how the state defines children who receive services that are funded 42 CFR § 438.50(d) under section 501(a)(1)(D) of title V. (Examples: children receiving services at a specific clinic or enrolled in a particular program.)

Not applicable.

1932(a)(2)

2. Place a check mark to affirm if the state’s definition of Title V children 42 CFR § 438.50(d)

is determined by:

i. program participation, ____ii. special health care needs, or ____iii. both.

CMS-PM-10120

ATTACHMENT 3.1-F Date: January 25, 2005

Page 9 OMB No.:0938-933 State: Mississippi ______________________________________________________________________________________________

Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014 1932(a)(2)

3. Place a check mark to affirm if the scope of these title V services 42 CFR § 438.50(d)

is received through a family-centered, community-based, coordinated care system.

____i. yes

____ii. no.

1932(a)(2)

4. Describe how the state identifies the following groups of children who are exempt 42 CFR § 438.50 (d)

from mandatory enrollment: (Examples: eligibility database, self- identification)

i. Children under 19 years of age who are eligible for SSI under title XVI;

The State identifies these children by category of eligibility and age through the MMIS Eligibility Subsystem.

ii. Children under 19 years of age who are eligible under section 1902 (e)(3) of the Act;

The State identifies these children by category of eligibility through the MMIS Eligibility Subsystem.

iii. Children under 19 years of age who are in foster care or other out- of-home placement;

The State identifies these children by category of eligibility through the MMIS Eligibility Subsystem.

iv. Children under 19 years of age who are receiving foster care or adoption assistance.

The State identifies these children by category of eligibility through the MMIS Eligibility Subsystem.

1932(a)(2) 5. Describe the state’s process for allowing children to request an exemption from 42 CFR § 438.50(d) mandatory enrollment based on the special needs criteria as defined in the state plan if they are not initially identified as exempt. (Example: self-identification)

Any child not initially identified as having special needs may request exemption from mandatory enrollment through self-identification.

1932(a)(2)

6. Describe how the state identifies the following groups who are exempt from

CMS-PM-10120

ATTACHMENT 3.1-F Date: January 25, 2005

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Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014 42 CFR § 438.50(d) mandatory enrollment into managed care: (Examples: usage of aid codes in the eligibility system, self- identification)

i. Recipients also eligible for Medicare.

The State identifies these individuals based on the Medicare indicator in the MMIS Eligibility System.

ii. Indians who are members of Federally recognized Tribes except when the MCO or PCCM is operated by the Indian Health Service or an Indian Health program operating under a contract, grant or cooperative agreement with the Indian Health Service pursuant to the Indian Self Determination Act; or an Urban Indian program operating under a contract or grant with the Indian Health Service pursuant to title V of the Indian Health Care Improvement Act.

The State identifies these individuals using information in the MMIS Eligibility Subsystem and through self-identification.

42 CFR § 438.50(2) F. List other eligible groups (not previously mentioned) who will be exempt from mandatory enrollment

Refer to B.5.

42 CFR § 438.50(2) G. List all other eligible groups who will be permitted to enroll on a voluntary basis

• Supplemental Security Income - 1902(a)(10)(A)(i)(II); Only beneficiaries under the age of 19 in the eligibility category of low income and age 65 or older, blind, or disabled receiving SSI cash assistance or deemed to be cash recipients.

• Disabled child at home – 1902(e)(3); Beneficiaries who are disabled and under the age of 19 qualify based on income under 300% of the SSI limit (nursing facility limit) meeting the level of care requirement for nursing facility/intermediate care facility for individuals with intellectual disabilities (ICF/IID) placement. Income and resource criteria are the same as for long term care rules and no parental deeming of income or other resources.

• Department of Human Services Foster Care and Adoption Assistance Children – 1902(a)(10)(A)(ii)(I) and 1902(a)(10)(A)(ii)(VIII); Beneficiaries up to age 19, if in the custody of the MS Dept. of Human

CMS-PM-10120

ATTACHMENT 3.1-F Date: January 25, 2005

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Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014 Services and in a licensed foster home, with eligibility based on income/resources of the child and resources not to exceed $10,000.

H. Enrollment Process

1932(a)(4)

1. Definitions 42 CFR § 438.50 i. An existing provider-recipient relationship is one in which the provider was the main source of Medicaid services for the recipient during the previous year. This may be established through state records of previous managed care enrollment or fee-for-service experience or through contact with the recipient.

ii. A provider is considered to have "traditionally served" Medicaid

recipients if it has experience in serving the Medicaid population.

1932(a)(4)

2. State process for enrollment by default 42 CFR § 438.50 Describe how the state’s default enrollment process will preserve:

i. The existing provider-recipient relationship (as defined in H.1.i).

Enrollees failing to make a voluntary CCO selection within the initial thirty (30) days of the enrollment process are auto-assigned to a CCO. Auto-assignment rules include a provision to verify paid claims data within a minimum of the past six (6) months and assignment of the enrollee to a CCO which has a contract with the enrollee’s primary care physician.

The use of claims data and CCO relationships for other family members is designed to preserve existing provider-recipient relationships.

ii. The relationship with providers that have traditionally served Medicaid recipients (as defined in H.1.ii).

Enrollees failing to make a voluntary CCO selection within the initial thirty (30) days of the enrollment process are auto-assigned to a CCO. Auto-assignment rules include provisions to:

 Verify paid claims data within a minimum of the past six (6) months and assign the enrollee to a CCO which has a contract with the enrollee’s primary care physician.

CMS-PM-10120

ATTACHMENT 3.1-F Date: January 25, 2005

Page 12 OMB No.:0938-933 State: Mississippi ______________________________________________________________________________________________

Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014  Determine if a family member is assigned to a CCO and assign the enrollee to that CCO.  If no family member is assigned to a CCO, the enrollee is assigned to an open panel closest to the enrollee’s home. If multiple CCOs meet this standard, auto-assignment occurs using a random process.

CCO provider networks for Medicaid beneficiaries are limited to Medicaid-participating providers. This ensures beneficiaries have a relationship with providers who have traditionally served Medicaid beneficiaries.

iii. The equitable distribution of Medicaid recipients among qualified MCOs and PCCMs available to enroll them, (excluding those that are subject to intermediate sanction described in 42 CFR § 438.702(a)(4)); and disenrollment for cause in accordance with 42 CFR § 438.56(d)(2). (Example: No auto-assignments will be made if MCO meets a certain percentage of capacity.)

Enrollees failing to make a voluntary CCO selection within thirty (30) days of enrollment are auto-assigned to a CCO. Auto-assignment rules include provisions to:

 Verify paid claims data within the past six (6) months and assign the enrollee to a CCO which has a contract with the enrollee’s primary care physician.  Determine if a family member is assigned to a CCO and assign the enrollee to that CCO.  If no family member is assigned to a CCO, the enrollee is assigned to an open panel closest to the enrollee’s home. If multiple CCOs meet this standard, auto-assignment will occur using a random process.

Auto-assignment is a hierarchy process, but in no case will auto-assignment exceed the capacity of the CCO’s provider network.

The use of claims data and CCO relationships for other family members is designed to preserve existing provider-recipient relationships.

CCO provider networks for Medicaid beneficiaries are limited to Medicaid- participating providers. This ensures beneficiaries have a relationship with providers who have traditionally served Medicaid beneficiaries.

CMS-PM-10120

ATTACHMENT 3.1-F Date: January 25, 2005

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Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014

1932(a)(4)

3. As part of the state’s discussion on the default enrollment process, include 42 CFR § 438.50

the following information:

i. The state will X / will not____ use a lock-in for managed care.

ii. The time frame for recipients to choose a health plan before being auto- assigned will be 30 days.

iii. Describe the state's process for notifying Medicaid recipients of their auto-assignment. (Example: state generated correspondence.)

Medicaid beneficiaries auto-enrolled receive State-generated correspondence informing of the assigned CCO.

iv. Describe the state's process for notifying the Medicaid recipients who are auto-assigned of their right to disenroll without cause during the first 90 days of their enrollment. (Examples: state generated correspondence, HMO enrollment packets etc.)

Medicaid beneficiaries auto-assigned to a CCO receive state-generated correspondence informing them that they may disenroll without cause during the first ninety (90) days of initial enrollment. CCO enrollment packets also provide information regarding disenrollment without cause during ninety (90) days of the initial enrollment date.

v. Describe the default assignment algorithm used for auto-assignment. (Examples: ratio of plans in a geographic service area to potential enrollees, usage of quality indicators.)

If the beneficiary fails to choose a CCO within thirty (30) days of the distribution date of the enrollment packet, the State assigns the beneficiary to a CCO. If it is not possible to determine prior patient/provider relationship, the State randomly assigns members to ensure equitable enrollment among the plans. If the plans have equitable distribution, then a round robin methodology is used to ensure maintenance of an equitable distribution.

vi. Describe how the state will monitor any changes in the rate of default assignment. (Example: usage of the Medical Management Information System (MMIS), monthly reports generated by the enrollment broker)

CMS-PM-10120

ATTACHMENT 3.1-F Date: January 25, 2005

Page 14 OMB No.:0938-933 State: Mississippi ______________________________________________________________________________________________

Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014 The State monitors for any change in the rate of auto-enrollment through data available from the MMIS Eligibility Subsystem and monthly enrollment reports generated by the enrollment broker.

1932(a)(4)

I. State assurances on the enrollment process 42 CFR § 438.50 Place a check mark to affirm the state has met all of the applicable requirements of choice, enrollment, and re-enrollment.

1. X The state assures it has an enrollment system that allows recipients who are already enrolled to be given priority to continue that enrollment if the MCO or PCCM does not have capacity to accept all who are seeking enrollment under the program.

2. X The state assures that, per the choice requirements in 42 CFR § 438.52, Medicaid recipients enrolled in either an MCO or PCCM model will have a choice of at least two entities unless the area is considered rural as defined in 42 CFR § 438.52(b)(3).

3. ____ The state plan program applies the rural exception to choice requirements of 42 CFR § 438.52(a) for MCOs and PCCMs.

X This provision is not applicable to this 1932 State Plan Amendment.

4. ____ The state limits enrollment into a single Health Insuring Organization (HIO), if and only if the HIO is one of the entities described in section 1932(a)(3)(C) of the Act; and the recipient has a choice of at least two primary care providers within the entity. (California only.)

X This provision is not applicable to this 1932 State Plan Amendment.

5. X The state applies the automatic reenrollment provision in accordance with 42 CFR § 438.56(g) if the recipient is disenrolled solely because he or she loses Medicaid eligibility for a period of two (2) months or less.

___This provision is not applicable to this 1932 State Plan Amendment.

1932(a)(4)

J. Disenrollment 42 CFR § 438.50 1. The state will X /will not___ use lock-in for managed care.

2. The lock-in will apply for up to twelve (12) months.

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Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014

3. Place a check mark to affirm state compliance.

X The state assures that beneficiary requests for disenrollment (with and without cause) will be permitted in accordance with 42 CFR § 438.56(c).

4. Describe any additional circumstances of “cause” for disenrollment (if any).

A beneficiary may request to disenroll from the CCO “with cause” if:

• The CCO, because of moral or religious objections, does not offer the service the beneficiary seeks, • The beneficiary needs related services to be performed at the same time, but not all related services are available within the network; or, the beneficiary’s primary care provider or another provider determines receiving the services separately would subject the beneficiary to unnecessary risk,

• Poor quality of care, • There is a lack of access to services covered under the CCO, or • There is a lack of access to providers experienced in dealing with the beneficiary’s health care needs.

K. Information requirements for beneficiaries

Place a check mark to affirm state compliance.

1932(a)(5) X The state assures that its state plan program is in compliance with 42 CFR § 42 CFR § 438.50

438.10(i) for information requirements specific to MCOs and PCCM programs 42 CFR § 438.10

operated under section 1932(a)(1)(A)(i) state plan amendments.

1932(a)(5)(D)

L. List all services that are excluded for each model (MCO & PCCM) 1905(t) Excluded services include:

• Inpatient hospital services.

• Long term care services, including nursing facility, ICF/IID, and PRTF.

• Any waiver services.

• Hemophilia services.

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Citation

Condition or Requirement ______________________________________________________________________________________________

______________________________________________________________________________________________ TN No. 14-024

Received Date 12-23-14 Supersedes

Approval Date 02/26/15 TN No. 2012-013 Effective Date 12/01/2014

CCOs are restricted from requiring its membership to utilize a pharmacy that ships, mails, or delivers drugs or devices.

1932 (a)(1)(A)(ii)

M. Selective contracting under a 1932 state plan option

To respond to items #1 and #2, place a check mark. The third item requires a brief narrative.

1. The state will X /will not______ intentionally limit the number of entities it contracts under a 1932 state plan option.

2. X The state assures that if it limits the number of contracting entities, this limitation will not substantially impair beneficiary access to services.

3. Describe the criteria the state uses to limit the number of entities it contracts under a 1932 state plan option. (Example: a limited number of providers and/or enrollees.)

The State limits the number of CCOs to no more than three (3) and no less than two (2) based on the number of potential enrollees. The State believes it is not in the best interest of the CCOs financially to divide the potential maximum among more than three (3) plans.

4. ____ The selective contracting provision is not applicable to this state plan.

Table of Contents

State/Territory Name: Mississippi State Plan Amendment (SPA) #:15-0001-MM2

This file contains the following documents in the order listed:

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

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

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

Atlanta Regional Office

61 Forsyth Street, Suite 4T20

Atlanta, Georgia 30303

CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

May 4, 2015

David J. Dzielak, Ph.D Mississippi Division of Medicaid Attn: Kristi Plotner

550 High Street, Suite 1000 Jackson, MS 39201-1399

RE: Title XIX State Plan Amendment (SPA), MS 15-0001-MM2 Dear Dr. Dzielak:

The Centers for Medicare & Medicaid Services (CMS) has completed its review of State Plan Amendment (SPA), Transmittal Number MS-15-0001-MM2. This SPA was received by the CMS on February 5, 2015 to incorporate the Modified Adjusted Gross Income (MAGI) based eligibility process requirements, including the single streamlined application into the Medicaid state plan in accordance with the Affordable Care Act. This SPA was approved on

May 1, 2015. The effective date of this SPA is January 1, 2015.

The approval of SPA MS-15-0001-MM2 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 will implement an online dynamic application by December 31, 2015 that addresses CMS concerns as outlined in the companion letter issued with this SPA approval.

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

e $94, pages S94-1, S94-2 Attachment 1 — State of Mississippi alternative single streamlined paper application

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

Dr. David J. Dzielak Page 2

CMS appreciates the significant amount of work your staff dedicated to preparing this SPA. If you have any questions concerning this SPA, please contact Tandra Hodges at 404-562-7409 or

by email at Tandra.Hodges@cms.hhs.gov.

Sincerely,

/Is// Jackie Glaze

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

Enclosures

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

Atlanta Regional Office

61 Forsyth Street, Suite 4120

Atlanta, Georgia 30303

CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

May 4, 2015

David J. Dzielak, Ph.D Mississippi Division of Medicaid Attn: Magaret Wilson

550 High Street, Suite 1000 Jackson, MS 39201-1399

RE: Title XIX State Plan Amendment (SPA), MS 15-0001-MM2 Companion Letter Dear Dr. Dzielak:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of State Plan Amendment (SPA) transmittal MS-15-0001-MM2, which was submitted to CMS on February 5, 2015. Our review of this submission included a review of the state’s alternative single streamlined paper application.

The state is currently using an interim alternative single streamlined online application and will implement the online dynamic application by December 31, 2015. 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, 2015 to allow time for review prior to December 31, 2015. CMS continues to be available to provide technical assistance. If you have any questions about your application, please contact Anne Chiang at Anne.Chiang@cms.hhs.gov. If you have any questions about this letter or require any further assistance, please contact Tandra Hodges at 404-562-7409 or by email at Tandra.Hodges@cms.hhs.gov.

Sincerely, /Is// Jackie Glaze

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

MS.1579.R00.00 - Jan 01, 2015 Page 1 of 1 Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory

name:

Mississippi ' 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-15-001

Proposed Effective Date 01/01/2015 (mm/dd/yyyy)

Federal Statute/Regulation Citation 42 CFR Sections 435.907, 457.40, and 457.330

Federal Budget Impact

Federal Fiscal Year Amount First Year 2015 $ 0.00 , Second Year 2016 $0.00 —— —_

Subject of Amendment Revision to the Mississippi Application For Health Benefits

Governor's Office Review Governor's office reported no comment ©: Comments of Governor's office received Describe: Approved No reply received within 45 days of submittal

Other, as specified Describe:

Signature of State Agency Official Submitted By: Margaret Wilson Last Revision Date: Apr 28, 2015 Submit Date: Feb 12, 2015

file:///S:/DMCH/State%20Plans/Mississippi/20 1 5/15-0001-MM2/A pproval/MS-15-000... 05/03/2015

cCcomMs Medicaid Eligibility

State Name: [Mississippi | Transmittal Number: MS - 15 - 0001

OMB Control Number: 0938-1148

Expiration date: 10/31/2014

42

CFR 435, Subpart J and Subpart M

Eligibility Process

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

Application Processing

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

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

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

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

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

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

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

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

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

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

The agency also accepts applications by other electronic means:

@ Yes C No

TN No.: 15-0001-MM2 Approval Date: 05/01/15

Effective Date: 01/01/15 Mississippi $94-1

cCCmMsS Medicaid Eligibility

CRATE Te MeN ARE A MURCIA NEY

Indicate the other electronic means below:

Name of Method Description

Applications received by fax will be accepted

Applications received by e-mail will be accepted

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

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

Redetermination Processing

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

[mM] Once every 12 months

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

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional

[M] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

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

[X] Once every 12 months [1] Once every 6 months (J Other, more often than once every 12 months

Coordination of Eligibility and Enrollment

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

TN No.: 15-0001-MM2

Approval Date: 05/01/15 Mississippi

Effective Date: 01/01/15 $94-2

CCMS Medicaid Eligibility

SON eM ERE AE A Ua CANT AREER

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 contro! number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

V.20140415

TN No.: 15-0001-MM2

Approval Date: 05/01/15 Mississippi

Effective Date: 01/01/15 $94-3 /o1

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

O Paper Application EJ Online Application

TRANSMITTAL NUMBER: STATE:

15-0001-MM2 Mississippi

—

Through December 31, 2015, the state is using an interim online alternative single streamlined application. After December 31, 2015, 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.

TN No.: 15-0001-MM2 Approval Date: 05/01/15 Effective Date: 01/01/15 Mississippi

MISSISSIPPI 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:

e Medicaid

e 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 assistance in completing this application, 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.medicaid.ms.gov or www.HealthCare.gov.

What you will need to apply:

e Social Security Numbers or document numbers for legal immigrants who need insurance,

e Birth dates,

e 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,

e Policy numbers for any current health insurance,

e 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 — revised 01/01/2015

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 1 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 01/01/2015

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 Sex: Of Male Birth Female

How is this

Is this person

person related to | applying?

you?

ay

SELF

OYes ONo

OYes ONo

OYes ONo

OYes ONo

OYes ONo

OYes ONo

OYes ONo

OYes ONo

ol] eo] ny] DA) WM BI] &] &

OYes ONo

— o

OYes ONo

*Social Security Numbers (SSN) ~ We need SSNs 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 SSNs of everyone. We use SSNs 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 www.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 01/01/2015

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? C] Yes C) 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? CL] Yes C1 No If yes, select your filing status: C] Married Filing Jointly () Married Filing Separately 0 Individual 11 Head of Household 0) Qualifying Widow(er) If filing jointly with spouse, name of spouse

Will you claim any dependents on your tax return? LJ Yes O) No If yes, name of dependents claimed:

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

Do you need health coverage? LI Yes If yes, answer all questions below. C1No 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 (1 No If you are disabled, would you like to apply for Medicaid as a disabled person? C1 Yes C1 No If yes, 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? O Yes C1 No _ 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 C1 No Are you or your spouse or parent a veteran or an active- duty member of U.S. military? [1 Yes D1 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? O1 Yes CNo 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, 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? LJ Yes C1 No If yes, in what state?

Race (optional) check all that apply: 1 White 1 Black O American Indian or Alaska Native L Chinese 1 Asian Indian O Filipino 0 Japanese 0 Korean 0 Vietnamese 1) Other Asian [1] Native Hawaiian

O Samoan O) Guamanian or Chamorro CL) Other Pacific Islander LJ Other If Hispanic/Latino, check all that apply (optional) 1) Mexican O Mexican-American () Chicano/a O Puerto Rican (1 Cuban CO Other

Part 6 / Person 1 - revised 01/01/2015

Person | - continued Current Job & Income Information: Are you currently: U Employed — How many jobs? O Self-employed — How many jobs? 0 Unemployed

Job #1: Employer Name

Employer Address & Phone:

Wages/tips (before taxes) $ QO Hourly 0 Weekly 0 Every 2 weeks (1 Twice month UJ 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 01 Every 2 weeks 0 Twice month O 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 you get from this self-employment? $ How often is this income received?

In the past year, did you: (1 Change jobs 01 Stop Working 0) 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: 0

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 01/01/2015

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? D0 Yes 1) No

Name —

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

Is this person pregnant? L] Yes C1 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 return next year? LD Yes O1No If yes, select filing status: DO) Married Filing Jointly (1 Married Filing Separately O Individual CO Head of Household U Qualifying Widow(er) If filing jointly with spouse, name of spouse

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

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

Does this person need health coverage? CL] Yes If yes, answer all questions below. OONo 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? LH Yes ONo If disabled, would this person like to apply for Medicaid as a disabled person? L] Yes 0) 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 C1 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 0 Yes U1 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? (1) Yes (1 No If yes, give names of child(ren) Do any of the children named have a parent living outside the home? 0 Yes U) 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 C1 No If yes, in what state?

Race (optional) check all that apply: (J White (1 Black 1 American Indian or Alaska Native O Chinese O Asian Indian O Filipino DO Japanese 0 Korean CO Vietnamese 1) Other Asian O Native Hawaiian 1) Samoan 1) Guamanian or Chamorro LD) Other Pacific Islander 1) Other If Hispanic/Latino, check all that apply (optional) 10 Mexican 1) Mexican-American O Chicano/a 0 Puerto Rican O) Cuban O Other

Part 6 / Person 2 - revised 01/01/2015

Person 2 — continued Current Job & Income Information: Is this person currently:

U Employed — How many jobs? O Self-employed — How many jobs? UO Unemployed

Job #1: Employer Name

Employer Address & Phone:

Wages/tips (before taxes) $ O Hourly O Weekly 0 Every 2 weeks 0) 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 O Weekly 0 Every 2 weeks (J Twice month O 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: C1 Change jobs 0) Stop Working UJ 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: O

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 01/01/2015

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? O Yes 0 No

Name —

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

Is this person pregnant? LJ Yes C1 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 return next year? C1 Yes OI No If yes, select filing status: C1 Married Filing Jointly 0 Married Filing Separately O Individual C1 Head of Household O Qualifying Widow(er) If filing jointly with spouse, name of spouse

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

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

Does this person need health coverage? L) Yes If yes, answer all questions below. OONo § 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? 11 Yes LJ 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? 0 Yes C1 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 0) Yes U1 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? LJ Yes O No If yes, names of child(ren) Do any of the children named have a parent living outside the home? LJ 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? C1 Yes CL] No If yes, in what state?

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

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

Part 6 / Person 3 - revised 01/01/2015

Person 3 — continued Current Job & Income Information: Is this person currently: C1 Employed ~ How many jobs? O Self-employed — How many jobs? 0 Unemployed

Job #1: Employer Name

Employer Address & Phone:

Wages/tips (before taxes) $ O Hourly 0 Weekly 0 Every 2 weeks 1) Twice month O Monthly O 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 0 Twice month O 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: 1] Change jobs 0 Stop Working O 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 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 01/01/2015