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Demonstration Approval Period: October 1, 2024 through September 30, 2029 Page 20 of 43

ADM – administration; DY – demonstration year; MAP – medical assistance payments; MEG – Medicaid expenditure group;

Demonstration Years. Demonstration Years (DY) for this demonstration are defined in the table below. Table 3: Demonstration Years Demonstration Year 21 October 1, 2024 to September 30, 2025 12 months Demonstration Year 22 October 1, 2025 to September 30, 2026 12 months Demonstration Year 23 October 1, 2026 to September 30, 2027 12 months Demonstration Year 24 October 1, 2027 to September 30, 2028 12 months Demonstration Year 25 October 1, 2028 to September 30, 2029 12 months

Budget Neutrality Monitoring Tool. The state must provide CMS with quarterly budget neutrality status updates, including established baseline and member months data, using the Budget Neutrality Monitoring Tool provided through the performance metrics database and analytics (PMDA) system. The tool incorporates the “Schedule C Report” for comparing the Table 2: MEG Detail for Expenditure and Member Month Reporting MEG (Waiver Name) Detailed Description Exclusions CMS-64.9 or 64.10 Line(s) To Use How Expend. Are Assigne d to DY MA P or AD M Report Membe r Months (Y/N) MEG Start Date MEG End Date Demonstration Population 1 Aged, blind, or disabled individuals enrolled in the demonstration at or below 135 percent of the FPL who are not eligible for Medicare and do not otherwise qualify for Medicaid. None Follow standard CMS-64.9 Category of Service Definitions

Date of service MA P Y 09/10/ 04 09/30/2 9