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Approval Period: April 1, 2019 through December 31, 2028 Page 23 of 28

Appendix A Annual Monitoring Report Template

Purpose and Scope of Annual Monitoring Report: The state must submit annual progress reports in accordance with the Special Terms and Conditions (STC) and 42 CFR 431.420. The intent of these reports is to present the state’s analysis of collected data and the status of the various operational areas, reported by month in the demonstration year. The report should also include a discussion of trends and issues over the year, including progress on addressing any issues affecting access, quality, or costs. Each annual monitoring report must include:

A. Executive Summary B. Utilization Monitoring C. Program Outreach and Education D. Program Integrity E. Grievances and Appeals F. Annual Post Award Public Forum G. Budget neutrality H. Demonstration evaluation activities and interim findings.

A. Executive Summary 1. Synopsis of the information contained in the report 2. Program Updates, Current Trends or Significant Program Changes a. Narrative describing the impact of any administrative and operational changes to the demonstration, such as eligibility and enrollment processes, eligibility redetermination processes (including the option to utilize administrative redetermination), systems, health care delivery, benefits, quality of care, anticipated or proposed changes in payment rates, and outreach changes. b. Narrative on any demonstration changes, such as changes in enrollment, renewal processes service utilization, and provider participation. Discussion of any action plan if applicable. c. Narrative on the existence of or results of any audits, investigations, or lawsuits that impact the demonstration. 3. Policy Issues and Challenges a. Narrative of any operational challenges or issues the state has experienced. b. Narrative of any policy issues the state is considering, including pertinent legislative/budget activity, and potential demonstration amendments. c. Discussion of any action plans addressing any policy, administrative or budget issues identified, if applicable.

B. Utilization Monitoring The state will summarize utilization through a review of claims/encounter data for the demonstration population in the subsequent tables. This includes the following:

Table 1. Summary of Utilization Monitoring Measures