Page 8

Approval Period: April 1, 2019 through December 31, 2028 Page 3 of 28

Centers for Medicare & Medicaid Services

SPECIAL TERMS AND CONDITIONS

NUMBER:

11 -W-00 276/8

TITLE:

Montana Plan First Section 1115 Family Planning Demonstration

AWARDEE: Montana Department of Public Health and Human Services

I. PREFACE

The following are the Special Terms and Conditions (STCs) for the Montana family planning section 1115(a) Medicaid demonstration (hereinafter “demonstration”). The parties to this agreement are the Montana Department of Public Health and Human Services and the Centers for Medicare & Medicaid Services (CMS). The STCs set forth in detail the nature, character, and extent of federal involvement in the demonstration and the state’s obligations to CMS during the life of the demonstration. The STCs are effective April 1, 2019 through December 31, 2028, contingent upon Montana’s compliance with demonstration STC 18 and 19. CMS reserves the right to withdraw demonstration authority if the state fails to meet the requirements in STC 18 and 19. All previously approved STCs, waivers, and expenditure authorities are superseded by the STCs set forth below.

The STCs have been arranged into the following subject areas:

I. Preface II. Program Description and Objectives III. General Program Requirements IV. Eligibility V. Benefits and Delivery Systems VI. General Reporting Requirements VII. Monitoring Calls and Discussions VIII. General Financial Requirements IX. Monitoring Budget Neutrality X. Evaluation

Appendix A: Annual Monitoring Report Template Appendix B: Evaluation Design Template

II. PROGRAM DESCRIPTION AND HISTORICAL CONTEXT

Demonstration Description

Montana’s section 1115 family planning demonstration entitled, “Montana Plan First,” has been operating since May 30, 2012. The demonstration extends eligibility for family