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Demonstration Approval Period: October 1, 2024 through September 30, 2029 Page 17 of 43

b) Number of providers in each locality of the taxing entities for each locality tax; c) Whether or not all providers in the locality will be paying the assessment for each locality tax; d) The assessment rate that the providers will be paying for each locality tax; e) Whether any providers that pay the assessment will not be receiving payments funded by the assessment; f) Number of providers that receive at least the total assessment back in the form of Medicaid payments for each locality tax; g) The monitoring plan for the taxing arrangement to ensure that the tax complies with section 1903(w)(4) of the Act and 42 CFR 433.68(f); and h) Information on whether the state will be reporting the assessment on the CMS form 64.11A as required under section 1903(w) of the Act. Extent of Federal Financial Participation for the Demonstration. Subject to CMS approval of the source(s) of the non-federal share of funding, CMS will provide FFP at the applicable federal matching rate for the following demonstration expenditures, subject to the budget neutrality expenditure limits described in the STCs in section VIII: a) Administrative costs, including those associated with the administration of the demonstration; b) Net expenditures and prior period adjustments of the Medicaid program that are paid in accordance with the approved Medicaid state plan; and c) Medical assistance expenditures and prior period adjustments made under section 1115 demonstration authority with dates of service during the demonstration extension period; including those made in conjunction with the demonstration, net of enrollment fees, cost sharing, pharmacy rebates, and all other types of third party liability. Program Integrity. The state must have processes in place to ensure there is no duplication of federal funding for any aspect of the demonstration. The state must also ensure that the state and any of its contractors follow standard program integrity principles and practices including retention of data. All data, financial reporting, and sources of non-federal share are subject to audit. Medicaid Expenditure Groups (MEGs). MEGs) are defined for the purpose of identifying categories of Medicaid or demonstration expenditures subject to budget neutrality, components of budget neutrality expenditure limit calculations, and other purposes related to monitoring