Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 1 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 2 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:______________ MONTANA_________________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

________Katherine Buckley-Patton__________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Mary Dalton Position/Title: State Medicaid and CHIP Director Name: Katherine Buckley-Patton Position/Title: HMK Program Director Name: Position/Title:

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 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 3 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1.

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3.

A combination of both of the above.

Montana has had a separate child health program since 1999. Effective October 1, 2009, income eligibility guidelines will increase from 175% of the federal poverty level (FPL) to 250% of the FPL. The name of the program will change from Montana Children’s Health Insurance Plan (CHIP) to the Healthy Montana Kids (HMK) coverage group of the Healthy Montana Kids Plan.

Effective October 1, 2009, DPHHS is implementing a CHIP-funded Medicaid Expansion Program for children 6-18 years of age whose family’s income is at or below 133% of the FPL. Children enrolled in the CHIP-funded Medicaid Expansion Program must meet all Medicaid eligibility requirements. They will receive the Medicaid package of benefits and access to the Medicaid network of providers. Provider reimbursement will be at the Medicaid provider rates. The CHIP-funded Medicaid Expansion Program will be part of the Healthy Montana Kids Plus coverage group of the Healthy Montana Kids Plan.

1.2.

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

Expenditures for child health assistance will not be claimed as certified on the CMS-21 expenditure report prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS.

1.3.

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 4 of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

Montana complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35.

1.4. Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Initial State Plan

Date of Plan submitted: April 13, 1998

Date Plan approved: September 11, 1998

State Plan effective date: January 1, 1998

State Plan Amendment Number 1

Date of Plan submitted: December 27, 1999

Date Plan approved: October 6, 2000

State Plan effective date: June 1, 2000

State Plan Amendment Number 2

Date of Plan submitted: July 1, 2002

Date Plan approved: September 27, 2002

State Plan effective date: July 1, 2002

State Plan Amendment Number 3

Date of Plan submitted: March 6, 2006

Date Plan approved: July 13, 2006

State Plan effective date: October 1, 2005

State Plan Amendment Number 4

Date Plan submitted: July 16, 2007

Date Plan approved: October 5, 2007

State Plan effective date: July 1, 2007; October 1, 2006

State Plan Amendment Number 5

Date Plan submitted: April 29, 2009

Date Plan approved: December 9, 2009

State Plan effective date: October 1, 2009

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 5

State Plan Amendment Number 6

Date Plan submitted: July 31, 2009

Date Plan approved: December 18, 2009

State Plan effective date: October 1, 2009

State Plan Amendment Number 7

Date Plan submitted: August 18, 2010

Date Plan approved: October 21, 2010

State Plan effective date: December 1, 2010

State Plan Amendment Number 8

Date Plan submitted: August 18, 2010

Date Plan approved: December 23, 2010 Date Plan effective date: See Below

1) Effective July 1, 2010 – Removal of some annual limits for inpatient and outpatient medical, mental health, and substance use disorder benefits, 2) Effective August 1, 2010 – Expanding Coverage to Children Lawfully Residing in the

United States, 3) Effective October, 1, 2009 -- Prospective Payment System for FQHCs and RHCs

(claims review and retrospective payment back to October 1, 2009,

implemented October 1, 2010) 4) Effective October 1, 2010: A. Apply as an exception to the three month insurance delay period children of military personnel who lose eligibility for Trico insurance (retroactive to October 1, 2009), B. Apply as an exception to the three month insurance delay period children from families with annual aggregate amount of premiums and cost-sharing exceeding 5 percent of family’s income, C. Addition of emergency ambulance services as a covered benefit and removal of cochlear implants and associated components as covered benefits, D. Increase the maximum basic dental benefit to $1,200 per member per benefit year, E. Programmatic updates related to tribal consultation, the schedule of mailings, and the appeals process; and 4) Effective January 1, 2011 – Provision of Presumptive Eligibility.

Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)- (3)) and (Section 2105)(c)(7)(A)-(B))

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 6 2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

The 2003 Montana Household Survey was conducted as a stratified random digit dial telephone survey. The data were collected by the Survey Research Center at the University of Montana – Missoula, Bureau of Business and Economic Research. The survey collected information on the health insurance status of each person in the household and some demographic information about the primary wage earner in the household. Seventeen percent (17%) or approximately 41,723 children between ages 0 through 18 were uninsured at all income levels and approximately 35,900 uninsured children lived in households at or below 200% FPL.

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

Montana has several efforts in place to identify and enroll all uninsured children who are eligible to participate in public health coverage programs.

Montana developed and maintains a statewide network of over 700 community partners, including health care providers, community advocacy groups, and other related agencies to increase awareness of the program, distribute applications, and offer enrollment assistance to families. In 2008, DPHHS distributed over 13,000 brochures and applications through this network.

In each of the past two years, DPHHS has conducted a comprehensive back-to-school campaign in the fall. Approximately 35,000 postcards with the theme ―Healthy Children Learn Better‖ were distributed to nearly 200 schools in 2008.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 7 In early 2006 DPHHS conducted a statewide media campaign, including television, radio, and print advertising. Department staff produced all of the campaign materials in-house. A similar campaign will be conducted in support of the implementation of the Healthy Montana Kids program in 2009 and 2010.

DPHHS staffs a telephone help-line for calls from Montanans in response to outreach campaigns, marketing, etc. Our staff is knowledgeable about requirements and services available from public health programs and Medicaid-funded programs. The staff responds to public inquiries, coordinates with these programs, and makes referrals.

Montana’s services and programs intended to assure health care access include:

1. Public health referral systems—Women, Infants and Children (WIC) Nutrition programs and public health home visiting services include assessment of high-risk conditions such as developmental, nutritional, psycho-social, and income factors. Clients with health care needs are referred to eligibility workers in local settings who determine whether the client is eligible to be covered by Medicaid-funded or CHIP-funded programs. In the case of programs for high-risk pregnant women, home visiting services and others may also do an initial screen for Medicaid eligibility authorizing clients for presumptive eligibility. WIC is funded with United States Department of Agriculture funding and public health home visiting is funded with a combination of Title V and State general fund resources.

2. Federally Qualified Health Centers—Montana has twenty –three (23) federally qualified health centers, forty-six (46) rural health clinics, twenty-six (26) Community Health Centers (CHCs) (fifteen centers and eleven satellites), five (5) Urban Indian Clinics and one (1) Migrant Health Clinic (with several satellite sites operated seasonally). Each facility has the resources to determine presumptive Medicaid eligibility for pregnant women, and distribute applications for Medicaid-funded and CHIP-funded programs. CHCs must also provide services regardless of the client’s ability to pay. Four of the Community Health Centers are co-located with public health departments and make referrals to assure access to health care. Community Health Centers use standard procedures to determine appropriate pay level for each client including providing a financial screen for each new patient or family, providing information on and explanation of services for which family members are eligible, assisting with completing applications and collecting required documentation, determining eligibility on-site or

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 8 forwarding applications to the determining agency, communicating with family members about eligibility status, and assisting families when their financial situation and eligibility changes. Healthy Montana Kids is implementing Medicaid’s outpatient prospective payment system rate for FQHCs and RHCs for health care services provided effective October 1, 2009.

3. Children’s Special Health Services (CSHS)—CSHS provides coverage for a limited number of children who have special health care needs. This program sponsors multi-specialty clinics and provides reimbursement for health care services if Medicaid or other health care insurance does not cover the services. The application for the CSHS program includes income determination to screen for Medicaid eligibility. CSHS program activities are funded with Title V resources.

4. Family Planning programs are contract services that identify clients in need of primary care services. They specifically target low-income clients. These clinics identify funding sources available to pay for preventive health services, including Medicaid and other insurance, and refer clients appropriately to those resources. The state supports Family Planning clinics with Title X funding, and local contributions may include Title V and other resources.

5. Rural Health Clinics (RHC) and National Health Service Corp (NHSC) providers are a loose network of primary care services throughout the state that allows clients to pay on a sliding fee scale. Forty-six (46) RHCs provide services on a sliding fee scale, and 18 NHSC providers, located in federally designated shortage areas, provide services on a sliding fee scale. RHCs may refuse service to clients, but NHSC must accept any client regardless of ability to pay. As previously mentioned, Healthy Montana Kids is implementing Medicaid’s outpatient prospective payment system rate for FQHCs and RHCs for health care services provided effective October 1, 2009.

6. Part C of the Individuals with Disabilities Education Act provides statewide early intervention services to meet the needs of Montana’s infants and toddlers with diagnosed disabilities or with developmental delays that warrant concern for a child’s future development. Children deemed eligible for Part C Services in Montana who appear Medicaid eligible are referred to the local county office for a Medicaid eligibility determination.

7. Montana’s Children’s Mental Health Services Plan (CMHSP) provides basic outpatient and other limited mental health services

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 9 through a single statewide fee-for-service program. CMHSP is not an insurance plan, but a capped appropriation. The Department of Public Health and Human Services (DPHHS) staff performs eligibility determinations.

8. Medicaid provides health coverage for low-income, elderly, blind and disabled Montanans who have limited resources. Infants born to Medicaid-enrolled women typically remain Medicaid eligible for twelve months. Family income for children ages zero (0) through eighteen cannot exceed 133% of poverty. Children are enrolled in the HMK Plus coverage group (formerly children’s Medicaid program). DPHHS administers the Medicaid Program and county public assistance offices determine eligibility for Medicaid or HMK Plus, Temporary Aid to Needy Families (TANF), and Supplemental Nutrition Assistance Program (SNAP).

9. Federally Qualified Health Centers, Health Care Clinics, Migrant Health Clinics, Tribal Health Clinics, and Indian Health Services facilities are presumptive Medicaid eligibility sites for pregnant women. Staff at these sites helps people apply for Medicaid by providing assistance in completing the application and then forwarding the application to county public assistance offices for eligibility determination.

Outreach to inform potential recipients about Medicaid is accomplished through the previously noted resources and by distributing Medicaid information to many health care advocacy groups and providers in Montana. Montana reaches thousands of children in the CHIP-funded outreach process, many of whom are Medicaid eligible.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

Montana has no health insurance programs that involve a public-private partnership.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

Model Application Template for the State Children’s Health Insurance Program

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Special outreach and coordination efforts are in place among HMK, Children’s Mental Health Services Plan and Children’s Special Health Services. If a child applies for one program and doesn’t qualify, or if the child may be served by more than one program, the child is appropriately referred. The state continues to streamline enrollment procedures and collaborative outreach efforts to further the plan’s goal to coordinate with other public and private programs. Families that do not qualify for HMK coverage receive information about other health care resources, which include Community Health Clinics, Shriner’s Hospital, Angel Flight, and many other health care resources, as appropriate.

Montana’s outreach and enrollment efforts are designed to maximize the number of children served under the Medicaid-funded and CHIP-funded programs. (We have no health insurance programs that involve a public- private partnership.) The state coordinates enrollment efforts with:

 Local public health departments  WIC  School Nutrition and Health Programs  Federally Qualified Health Care Centers which include Community, Urban Indian, and Migrant Health Centers  Case Management Providers  Family Planning and Planned Parenthood Centers  Rural Health Clinics  Children’s Special Health Service Plan  County Eligibility Case Managers and TANF Case Managers  Indian Health Services  Tribal Health Services  Early Intervention Services (Part C)  Child Support Enforcement  Child Protective Services  Head Start and Early Head Start  State of Montana and Montana University System Employee Health Care Benefits  Other Programs as they are identified

These providers:  Inform participants in their programs of the Healthy Montana Kids Plan  Distribute brochures and applications for the Healthy Montana Kids Plan

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 11 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

Montana’s population is approximately 957,861. Of this number, excluding Medicare Advantage Plan enrollees, there are approximately 43,693 HMO certificate holders receiving health care services through a Health Maintenance Organization (HMO). A low penetration rate for managed care required that Montana rely primarily on indemnity insurance plans for coverage. DPHHS offered to contract with indemnity plans willing to meet the contracting criteria. In this way, DPHHS hoped to offer clients a choice in the more populated areas of the state. Until September 2006, DPHHS contracted with one indemnity plan, Blue Cross Blue Shield of Montana, and no HMOs.

In an effort to decrease administrative expenses, DPHHS issued a Request for Proposal (RFP) for Third Party Administrative (TPA) Services in early 2006. DPHHS contracted with Blue Cross Blue Shield of Montana for TPA services effective October 1, 2006.

The third party administrative (TPA) contract addresses the following areas: cost sharing, enrollment, marketing, benefits, provider network, utilization management, quality of care, access to care, member rights, civil rights, and grievance procedures. Contract standards are based on a review of standards from the following sources: National Association of Insurance Commissioners (NAIC) Model Acts, National Committee for Quality Assurance (NCQA) Accreditation Standards, and existing Medicaid contracts.

Montana may vary significantly from provider standards established in other states. Montana is a frontier state characterized in the east by sparsely populated plains and in the west by small clusters of populations separated by mountain ranges. Given the diversity in geography and population density, Montana is unable to use a single distance and/or travel time to gauge adequacy of a provider network. Instead, availability of primary care practitioners and specialists in the normal service delivery area is decided for each town or locale. This model which is used by HMK has proven successful

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 12 in our Medicaid PASSPORT program (our primary care case management model) that has been in operation since 1993. We find in a frontier state such as Montana this case-by-case approach is more meaningful to clients who are accustomed to, and often choose to, live extended distances from services.

Essential Community Providers: The TPA contractor is required to offer a provider network contract to Title X Family Planning providers, Indian Health Service providers, Tribal Health providers, Urban Indian Centers, Migrant Health Centers and county public health departments. The contract must offer terms and conditions at least as favorable as those offered to other entities providing the same or similar services. This provision is only in effect, however, if the afore-named entities substantially meet the same access and credentialing criteria as other contract providers and only for geographic areas jointly served by the entities and the plan.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

The TPA contractor performs primary utilization management functions. Contract standards require adequate staff and procedures to ensure services provided to enrollees are medically necessary and appropriate. At a minimum, the TPA Contractor must address the use of referrals, prior authorizations, and client educational services.

The TPA Contractor must comply with requirements of applicable Montana law and rules governing health care quality control.

The TPA contractor’s physician incentive plans shall include no specific payment directly or indirectly to a physician or physician group as an inducement to reduce or limit medically necessary benefits furnished to a child.

The TPA Contractor is required to have an external quality review process.

DPHHS must approve the complaint resolution process for addressing enrollees’ complaints and appeals. Upon enrollment, and at least annually thereafter, the TPA Contractor must inform enrollees of the complaint resolution process. The TPA Contractor must submit quarterly reports to

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 13 DPHHS summarizing any complaint handled during the previous quarter. DPHHS must review all contractor complaint decisions.

The TPA Contractor must submit Healthcare Management Reports on a quarterly basis and the following HEDIS measures on an annual basis: access to primary care, childhood immunization status, adolescent immunization status, appropriate use of asthma medications, well-child visits (in the first 15 months and annually from age three to six) and adolescent well-care visits.

The TPA Contractor encourages the use of a primary care provider (PCP) to serve as a child’s medical home. The PCP should perform all routine non- emergency care for the child and make necessary arrangements for a child who needs referral to a specialist or hospital. A specialist could serve as a child’s primary care provider. The state Medicaid program has extensive experience in using a PCP system and offers technical assistance.

The TPA Contractor includes in its educational materials for enrollees and providers information about additional services available to children with special health care needs. Examples of these services are the Children’s Mental Health Services Plan, Children’s Special Health Services (Title V), public health case management services for pregnant women and children.

Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1.

Geographic area served by the Plan:

4.1.2.

Age: The HMK coverage group (separate CHIP program) is available to children ages zero through eighteen. Coverage for a child will continue through the end of the month of the child’s 19th birthday.

4.1.3.

Income: Children from families whose adjusted gross income is at or below 250% of the federal poverty level are eligible for the

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 14 HMK coverage group (CHIP) effective October 1, 2009. Earned (wages, tips, salaries, etc.) and unearned (child support, unemployment, etc.) income is counted when determining adjusted gross income. Any income excluded by other federal statute is not counted.

The current HMK Plus (Medicaid) eligibility guidelines are up to 133% FPL for children less than 6 years of age and up to100% FPL for children between 6 and 18 years of age.

The CHIP-funded Medicaid expansion program will provide HMK Plus coverage group benefits for children 6 -18 years of age with family incomes between 101% and 133% FPL. All eligible children in a family regardless of the age of the children will have HMK Plus coverage if the family income is 133% FPL or less. This standard eligibility guideline makes it easier for families because the children are enrolled in the same coverage group, have the same benefits and provider network.

During FFY 2010 CHIP members who are 6-18 years of age and have family incomes at or below 133% FPL will transition to the CHIP Medicaid expansion program in the HMK Plus coverage group at the time of their annual renewal. Due to this staggered transition to the CHIP Medicaid expansion program, there will be a declining number of children with incomes below 133% FPL in the HMK coverage group (CHIP). By September 2010 all eligible children with family incomes at or below 133% FPL will be enrolled in HMK Plus and those with family incomes between 134% and 250% will be in the HMK coverage group.

DPHHS excludes $1,440 per year for each family member whose earned-income is counted. DPHHS also excludes $2,400 per year for each person for whom dependent care is paid. Montana DPHHS did not revise these two income disregards when the income change was made from 175% to 250% FPL.

For purposes of determining financial eligibility for the HMK coverage group, a family unit consists of:

1. The child for whom the family is applying 2. The natural or adoptive parents of the child 3. The spouse of the child’s natural or adoptive parent 4. The child’s siblings (natural, adoptive, half, or step) from ages zero through eighteen, with the following

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 15 exception: If a sibling between ages 19 through 22 is attending school, he or she may be counted in the family unit. 5. The child’s (i.e., emancipated minor) spouse

An unmarried emancipated minor who applies for the program is considered his or her own family.

Effective October 1, 2009, DPHHS requires income verification when a family applies for the HMK Plan. Families are required to provide documentation for all countable income.

4.1.4.

Resources (including any standards relating to spend downs and disposition of resources):

4.1.5.

Residency (so long as residency requirement is not based on length of time in state): U.S. Citizenship and Montana residency are required. A Montana resident is anyone who declares him-or- herself to live in the state, including migrant and other seasonal workers. The parent is required to certify on the application that the child is a U.S. citizen, or Qualified Alien and a Montana resident. Montana follows federal guidelines in determining whether a child is a U.S. citizen, or Qualified Alien.

DPHHS requires citizenship verification for the HMK Plus coverage group including the CHIP-funded Medicaid expansion program. DPHHS is implementing citizenship verification for the HMK coverage group effective October 2009. DPHHS allows enrollment in the HMK Plan (HMK and HMK Plus) with a reasonable opportunity to verify citizenship or residency status. If the HMK application states the child was born in Montana, DPHHS will verify citizenship through Montana vital records. When the Social Security Administration’s citizenship electronic verification system is available, DPHHS will apply for access. Until the SSA electronic database is available for citizenship verification, DPHHS will require original documents for verification of citizenship or residency status for children not born in Montana. As of January 1, 2010 HMK is successfully using the SVES interface to verify citizenship and identity on 97 percent of all new applicants.

4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): No child is denied eligibility based on disability status. If the child receives SSI and is eligible

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 16 for Medicaid, the child is denied coverage because of Medicaid eligibility not for disability status.

4.1.7.

Access to or coverage under other health coverage: A child is

found ineligible when: 1) the child is covered under a group

health plan or under health insurance coverage as defined in

section 2791 of the Public Health Service Act; 2) the child is

eligible for Medicaid.

Eligible children of State of Montana and Montana University System employees are covered in accordance with the Patient Protection & Affordable Care Act of 2010 ―Hardship Exception to the Exclusion of Children of Employees of a Public Agency in a State‖.

The methodology for determining eligibility for State of Montana and Montana University System employee’s children is a two- fold test. First, the program determines if the family meets all financial and HMK coverage group (CHIP) eligibility requirements.

Second, the program compares the family’s income to the reference table for their health insurance plan out of pocket expense requirement. It is a reasonable expectation out of pocket expenses, including premiums, deductibles, coinsurance and copayments, will exceed 5% of a family’s income for families with income at or below 250% of the FPL.

The program assures an annual review of the updated state employees’ health insurance plans’ reference table. This review will evaluate the out of pocket expense requirements to assure this reasonable expectation remains valid for families at or below 250% of FPL.

4.1.8.

Duration of eligibility: Eligibility is redetermined every 12 months.

Once a child is determined eligible, he or she remains eligible unless the child moves from the state, moves in-state and DPHHS is unable to locate the family, family initiates an application and is found eligible for the HMK Plus coverage group, is found to have other creditable health insurance coverage, turns 19, dies, becomes an inmate of a public institution, or the applicant fails to reapply or reapplies and the child is determined ineligible.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 17

Eligible children on the initial application will have the same 12 month continuous eligibility period. Children who enroll at a later date may receive less than 12 months of continuous eligibility during their first year of enrollment. DPHHS chose to add the new child to the existing eligibility period in order to synchronize the reapplication/renewal period for all children in the family. Without this policy, a family would be required to re-apply for coverage for various children in the family at multiple times throughout the year.

4.1.9.

Other standards (identify and describe): A Social Security Number (SSN) is required for a child who applies for benefits. Services are not denied or delayed to an otherwise eligible child pending issuance of the child’s SSN. The program follows all HIPAA related confidentiality standards and restricts the use or disclosure of information concerning applicants and enrollees to purposes directly connected with administration of the plan.

4.1.10.

Check if the State is electing the option under section 214 the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following:

A child or pregnant woman shall be considered lawfully present if he or she is:

(1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. § 1641);

(2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission;

(3) An alien who has been paroled into the United States pursuant to section 212(d)(5) the Immigration and Nationality Act (INA) (8 U.S.C. § 1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution for deferred inspection or pending removal proceedings:

(4) An alien who belongs to one the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A the INA (8 U.S.C. §§ 1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 the INA (8 U.S.C. § 1254a), and pending applications for TPS who have been granted employment

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Approval Date: 18 authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended; (v) Aliens currently under Deferred Enforcement Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status;

(5) A pending applicant for asylum under section 208(a) the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) or the INA (8 U.S.C. § 1231) or under the Convention Against Torture who have been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days;

(6) An alien who has been granted withholding of removal under the Convention Against Torture;

(7) A child who has a pending application for Special Immigration Juvenile status as described in section 101a(27)(J) the INA (8 U.S.C. § 1101(a)(27)(J));

(8) An alien who is lawfully present in the Commonwealth the Northern Mariana Islands under 48 U.S.C. § 1806(e); or

(9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

The State elects the CHIPRA section 214 option for children up to age 19

The State elects the CHIPRA section 214 option for pregnant women through the 60-day postpartum period

4.1.10.1. The State provides assurance that for individuals whom it

enrolls in CHIP under the CHIPRA section 214 option that

it has verified, both at the time of the individual’s initial

eligibility determination, and at the time of the eligibility

redetermination, that the individual continues to be

lawfully residing in the United States. The State must first

attempt to verify this status using information provided at

the time of the initial application. If the State cannot do so

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from the information readily available, it must require the

individual to provide documentation or further evidence

to verify satisfactory immigration status in the same

manner as it would for anyone else claiming satisfactory

immigration status under section 1137(d) of the Act.

CHIP and Medicaid work collaboratively and closely on

policies relating to lawfully residing children. Both

programs define ―lawfully residing‖ in the same manner.

The State is not choosing the enhanced match, since

Medicaid estimates no more than six children in the state

will meet the LAPR criteria and the administrative

expenses added for separately tracking those children

exceed the costs of receiving an enhanced match.

Currently only one child meets this criteria in Medicaid,

and the Medicaid policy has been in effect since January,

2010.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1.

These standards do not discriminate on the basis of diagnosis.

4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income.

4.2.3.

These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

DPHHS will implement a combined application for the HMK Plan. This application will be distributed statewide and is accessible on the Internet. Both the HMK Plan office and county Offices of Public Assistance will continue accepting and processing previous versions of the programs’ applications.

DPHHS will accept and determine eligibility for all applications for children’s health coverage provided by the Healthy Montana Kids Plan. Applications may be submitted directly to the Healthy Montana Kids Plan office or any county Office of Public Assistance (OPA). DPHHS staff in each location will screen for potential eligibility for the HMK Plan. Staff at the OPA and HMK Plan offices

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Approval Date: 20 will coordinate eligibility determination activities and enroll eligible children in the appropriate HMK Plan coverage group, HMK or HMK Plus.

DPHHS is developing and implementing a computerized eligibility determination system for DPHHS health and social service programs e.g. Medicaid, Supplemental Nutrition Assistance Program (SNAP), etc. The HMK Plan will be a module in this eligibility determination system. The system will improve the accuracy and coordination between the HMK Plan coverage groups and with other DPHHS programs.

DPHHS performs the following functions as part of the eligibility determination process:

 Log and scan applications and pertinent documents into the electronic file system;  Process applications;  Determine eligibility;  Refer applicants to Children’s Special Health Services, Children’s Mental Health Services, Montana Community Health Centers, or private health plans, as appropriate (Referral to other programs will not stop the HMK Plan eligibility determination process.);  Staff a toll-free information number families may call to receive information about children’s health coverage and eligibility;  Send annual renewal notices to enrollees;  Provide support for application and outreach sites;  Provide a complaint process for applicants;  Facilitate a smooth transition between different DPHHS providers and private insurances;  Provide eligibility data needed for annual reports;  Conduct Quality Assurance Audits; and  Provide a listing of HMK Enrollment Partners and CHIPRA Coalition Partners.

Eligibility Determination:

Children ages zero to 19 in families whose countable income is at or below 250% of the federal poverty level are eligible if all other eligibility criteria are met.

DPHHS eligibility is determined within forty-five calendar days of receipt of a completed application. By the forty-fifth calendar day, a letter is sent to the family notifying them of the children’s eligibility status or requesting more information to complete the application process.

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The eligibility determination time period for the application begins the first of

the month after DPHHS receives the application. DPHHS processes the

application and will contact the family if additional information is required.

DPHHS will provide temporary HMK coverage group benefits to uninsured children under age 19 during a period of presumptive eligibility following a determination by a qualified presumptive eligibility provider. The effective date for implementing presumptive eligibility is January 1, 2011.

Temporary HMK coverage group benefits will begin on the date a qualified entity trained and certified by HMK makes a determination of presumptive eligibility based on information provided by the child’s parent or guardian on a presumptive eligibility application. Presumptive eligibility will end on the earlier of the date HMK makes a determination of eligibility for HMK group coverage, or the last day of the month following the month presumptive eligibility begins. During the first phase of implementing presumptive eligibility, DPHHS will train and certify Montana hospital staff members to serve as qualified entities. The state has developed a presumptive eligibility application and will distribute the presumptive eligibility and HMK Plan applications to qualified entities. The qualified entity will provide a presumptive eligibility application to the family and will make a determination of presumptive eligibility based on information self-declared by a child’s parent or guardian. The qualified entity will give the parent or guardian a copy of the presumptive eligibility determination to use for verification of HMK eligibility. The family will show the presumptive eligibility confirmation when seeking health care services during the presumptive eligibility period. The qualified entity also will give the parent or guardian an HMK Plan application which must be submitted to DPHHS prior to the end of the presumptive eligibility period so ―regular‖ enrollment in the HMK Plan can be evaluated. If the child’s family does not return the HMK Plan application within the presumptive eligibility period, the child will be disenrolled at the end of the presumptive eligibility span. When the presumptively eligible family submits an HMK Plan application within the appropriate timeline, DPHHS will determine eligibility for the HMK coverage group and the HMK Plus coverage group. If the child is ineligible for either coverage group, the child will be disenrolled on the date ineligibility is determined.

Enrollment in the Health Plan: Eligible children are enrolled on the first day of the month after the Department receives the application. For example, an application is received on October 15th and children are determined eligible on November 10th. Enrollment is November 1st.

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Approval Date: 22 Redetermination of Eligibility: Children are continuously eligible unless the child’s status changes (see Section 4.1.8). Applicants must complete and submit a renewal application every twelve months. The renewal application is pre-printed with some information and is sent to the applicant for review and update. If the completed renewal application is not returned, the coverage terminates. Applicants may reapply for coverage at a later date. Children will not, however, be given preference for coverage and may be placed on the waiting list, if one exists. Enrollment is subject to available funding.

The following is a schedule of renewal mailings sent to families:

 Renewal packets are mailed to families 10 months after children are determined eligible.  Send 15 day notice of closure at 11.5 months.  Send closure notice at end of 12 months if no renewal application is returned.  Send fail to comply notice at end of 12 months if more information is requested but not returned.

4.3.1. Describe the state’s policies governing enrollment caps and waiting lists (if

any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

Montana currently has no waiting list, but our enrollment is limited by federal and state funds that have been appropriated to the program. If Montana should need to establish a waiting list in the future, the following procedure will be implemented. When the maximum number of children is enrolled, the enrollment is capped and a waiting list is established. The waiting list is for children determined eligible but for whom space is not available. Children are placed on the waiting list in the order in which they are determined eligible. Applicants are notified in writing if their children are eligible and placed on the waiting list. Applicants are also informed that they can contact DPHHS to inquire about their child’s position on the waiting list. Spaces become available at the end of each month when enrollment ends for currently enrolled children who:

1. turned age 19;

2. became eligible for HMK Plus coverage;

3. obtained coverage under another insurance;

4. moved out of state;

5. failed to reapply;

6. reapplied but were determined ineligible;

7. moved within the state and DPHHS is unable to locate the family; or

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8. died.

When space becomes available, children are removed from the waiting list and enrolled until all spaces are filled. Applicants are notified in writing when their children are taken off the waiting list and are enrolled. Children on the waiting list are enrolled based on when they are determined eligible.

If space is available for at least one child, families with more than one eligible child on the waiting list will have all children enrolled at the same time. The children will all have the same enrollment date.

A child determined eligible who has a sibling already enrolled will not be placed on the waiting list. The newly eligible child is enrolled the first of the month after the Healthy Montana Kids Plan is notified. The renewal date for the newly eligible child will be the same as currently enrolled sibling.

Note: There is no waiting list for the HMK Plus coverage group, including the CHIP Medicaid expansion program.

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including a state health benefits plan) are furnished child health assistance under the state child health plan. (Section 2102)(b)(3)(A)) (42CFR 457.350(a)(1) and 457.80(c)(3))

The application asks if a child applying for health coverage was covered by health insurance within the past three months. If the answer is yes and the coverage did not end due to one of the allowable exceptions, the child is not eligible for enrollment until the three month uninsured period passes.

Montana’s high number of families living below 250% FPL and high rate of uninsured children, coupled with Montana’s economy, are indicators that Montana’s low-income children are uninsured because their parents are unable to afford dependent health insurance. More than 50% of Montana’s employers are small employers (less than 50 employees) and most are unable to provide health insurance benefits for their employees. The application asks the applicant to report any health insurance

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Approval Date: 24 coverage. If the family reports creditable coverage as defined in section 2791 of the Public Health Service Act, the child is found ineligible. The TPA Contractor, Blue Cross Blue Shield of Montana (BCBSMT) is the largest health insurance carrier in Montana and is required contractually to notify DPHHS whenever they have reason to believe an enrollee has other coverage. DPHHS staff will investigate and if the child has other creditable insurance coverage, coverage will end.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

DPHHS staff screen applicants for HMK Plus eligibility.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4)) If department staff determine a child is ineligible for HMK Plus, the staff will evaluate the application for HMK eligibility.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

Families must indicate on the HMK application if the children had insurance during the past three months prior to application.

A child is ineligible if he or she has been covered under a creditable health plan during the minimum three month ―insurance delay period‖ prior to applying. The three month period is waived if:

1) The parent or guardian providing the insurance:

a. dies;

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b. is terminated or laid off;

c. can no longer work because of a disability;

d. has a lapse in insurance coverage because he

or she obtains new employment;

e. had insurance coverage that ended because the

step-parent, who provided the coverage, and the

parent divorced;

f. had coverage through the Insure Montana

Program;

g. had coverage through the Medicaid Health

Insurance Premium Payment Program;

h. paid more than 50% of the insurance premium;

i. has insurance coverage that is not accessible

(e.g. coverage is through an HMO in another

state);

j. loses Tricare military health insurance; or

k. has an aggregate amount of health insurance

premiums and cost-sharing expenses imposed for

coverage of a family of a child which exceeds 5

percent of the family’s income.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

See response to 4.4.4.1.

4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution.

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4.4.4.4. If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

The cost-effectiveness determination.

4.4.5. Child health assistance is provided to targeted low-income children in

the state who are American Indian and Alaska Native. (Section

2102)(b)(3)(D)) (42 CFR 457.125(a))

DPHHS works directly with tribes, the Indian Health Service, Tribal Health Services, and Urban Indian Centers to inform Native Americans in Montana about the HMK Plan. The TPA Contractor is required to offer a provider contract to Urban Indian Centers, Indian Health Service and Tribal Health Service providers who meet certification qualifications. See Sections 3.1 and 9.9 for more information.

If any child determined eligible is identified as Native American or an Alaska Native, there is no cost-sharing for that family. The identification card each child receives from the TPA Contractor indicates that no co- payment is required when that child receives services.

Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish: Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

A media campaign to reach families with children potentially eligible for health coverage will be conducted in FFY 2009 and 2010. Media message commercials will be broadcast on radio and television and news releases published in daily and weekly newspapers, specialty publications and professional association newsletters. Additionally, many DPHHS providers

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Approval Date: 27 display applications in their waiting rooms.

Assumptions about the target population are based on the experience of the Medicaid Program, social services programs, health care agencies and providers. For an audience consisting of families with a variety of financial needs, DPHHS must appeal both to those who have regular interaction with human service agencies, and to working low-income families who traditionally avoid government programs. Outreach efforts emphasize this is a low-cost health coverage plan that is a collaborative effort between families and the state and federal governments to ensure children receive health care.

Direct Appeal to Eligible Families through Press Releases, Public Service Announcements, Brochures, Posters, and Videos: DPHHS airs radio and television public service announcements about health care coverage programs for children. A toll-free number to call for more information is featured in the public service announcements, printed materials, and press releases. Occasional news releases are sent to the media about the increased insurance coverage available to children. Radio stations, TV and cable stations, Montana daily and weekly newspapers, and specialty publications and newsletters for professional associations in children's health care, parenting, day care, and education receive the press releases and news items.

Outreach methods, other than written materials, are employed whenever possible. All outreach materials prominently feature DPHHS toll-free telephone number. Callers to the toll-free number speak to a customer service representative or leave their name and address to receive an application. Brochures and posters are prominently displayed in locations frequented by low-income families with children.

Outreach through Schools: DPHHS collaborates with Healthy Mothers Healthy Babies (Covering Kids grantee) and the Office of Public Instruction to conduct back-to-school enrollment campaigns in school districts statewide. Information is sent to schools to help conduct outreach. School nurses and counselors are an important part of school-based outreach. Articles and information in school newspapers is another way to reach families. DPHHS works with the Free- and-Reduced School Lunch Programs to distribute information to families.

Outreach through Collaboration with Local Agencies, Grassroots Organizations, and Providers: Outreach training sessions on eligibility are provided to a variety of staff including: county public health departments, county social services, WIC coordinators, county public assistance offices, family resource centers,

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Approval Date: 28 churches, the program for Children with Special Health Care Needs, community-centered boards of grassroots organizations, Child Care Resource and Referral agencies, tribal health and social services staff, and Head Start.

Outreach is conducted through DPHHS home visits and case management programs. Home visitors give HMK Plan information and answer questions from pregnant women, parents and families.

DPHHS works with Native American leaders, both urban and reservation, to develop specific outreach activities for this population.

Outreach through Collaboration with Statewide Maternal Child Health Organizations: DPHHS staff operate the Maternal Child Health (MCH) toll-free help line which dispenses information about MCH programs, HMK and other health coverage programs and resources.

The Montana Council for Maternal and Child Health does a series of community forums every other year where family health care issues are discussed. They prominently feature children’s health coverage program information in these forums.

Applications are available to families at FQHCs, community health and public health centers, IHS tribal sites, county Offices of Public Assistance, WIC offices, health care providers’ offices, numerous community locations, and on the Internet at www.HMK.mt.gov. While many of these sites have personnel or advocates available to assist families in completing the application, the eligibility determination is not actually performed at these sites.

The Healthy Montana Kids Plan staff work closely with the Family and Community Health Bureau, which administers Montana’s MCH Title V Block Grant to ensure maximum coordination between programs.

Outreach through HMK Plan Enrollment Partners: The department will also conduct outreach through the following qualified entities: licensed health care providers, school districts, community-based organizations, government agencies and Indian Health Services. The department will consider requests to act as an Enrollment Partner from other entities and approve requests on a case by case basis.

A qualified entity becomes an Enrollment Partner by contacting the department and indicating an interest in becoming an enrollment partner. The department will provide an Enrollment Partner with HMK and HMK Plus materials and applications. Enrollment Partners must complete department

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Approval Date: 29 sponsored training and provide application assistance to Healthy Montana Kids Plan applicants. The department will maintain a list of the names, addresses, and telephone numbers of its enrollment partners and publish the list on its web site.

Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420)

6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.)

6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

DPHHS continues to offer benchmark-equivalent coverage of Montana state employee health insurance. The actuarial report and supporting documentation were submitted with the state plan amendment dated August 1, 2000, and remain unchanged.

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing

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Approval Date: 30 comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1. Coverage the same as Medicaid State plan

6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project

6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population

6.1.4.4. Coverage that includes benchmark coverage plus additional coverage

6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage

6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done)

6.1.4.7. Other (Describe)

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

For the separate CHIP program the following statements apply to all services covered in this section (6.2):

1. There are no pre-existing condition limitations. 2. Experimental procedures, custodial care, personal comfort, hygiene, or convenience items that are not primarily medical in nature, whirlpools, organ and tissue transplants, TMJ treatment, treatment for obesity,

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Approval Date: 31 acupuncture, biofeedback, neurofeedback, chiropractic services, elective abortions, in vitro fertilization, gamete or zygote intrafallopian transfer, artificial insemination, reversal of voluntary sterilization, transsexual surgery, fertility enhancing treatment beyond diagnosis, cosmetic surgery, radial keratotomy, cochlear implants and associated components, private duty nursing, treatment for which another coverage such as workers compensation is responsible, routine foot care, services for members confined in criminal justice institutions, and any treatment not medically necessary are not covered benefits. These exclusions are in addition to any exclusion noted in the individual coverage descriptions.

6.2.1.

Inpatient services (Section 2110(a)(1)): Semi-private room; intensive and coronary care units; general nursing; drugs; oxygen; blood transfusions; laboratory; imaging services; physical, speech, occupational, heat, and inhalation therapy; operating, recovery, birthing and delivery rooms; routine and intensive nursery care for newborns; and other medically necessary services and supplies for treatment of injury or illness are covered.

Coverage of postpartum care for at least forty-eight hours for vaginal delivery and ninety-six hours for cesarean section is guaranteed.

Services for mental and chemical dependency disorders are outlined in Sections 6.2.10 and 6.2.18.

Organ and tissue transplants are not covered.

6.2.2.

Outpatient services (Section 2110(a)(2)) All services described in 6.2.1 which are provided on an outpatient basis in a hospital (including but not limited to observation beds and partial hospitalization services) or ambulatory surgical center; chemotherapy; emergency room services for surgery, accident or medical emergency; and other services for diagnostic or outpatient treatment of a medical condition, accident, or illness are covered.

Services for mental and chemical dependency disorders are outlined in Sections 6.2.11 and 6.2.19.

6.2.3.

Physician services (Section 2110(a)(3)): Office, clinic, home,

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Approval Date: 32 outpatient surgical center and hospital treatment for a medical condition, accident, or illness by a physician, naturopathic physician or advance-practice registered nurse are covered.

Well-child, well-baby, and immunization services as recommended by the American Academy of Pediatrics are covered.

Routine physicals for sports, employment, or required by a government authority are covered.

Anesthesia services rendered by a physician anesthesiologist (other than the attending physician or assistant) or by a nurse anesthetist are covered provided that surgical and/or hospital benefits are also covered. Hypnosis, local anesthesia (unless it is included as part of a global procedure charge), and consultations prior to surgery are not covered.

6.2.4.

Surgical services (Section 2110(a)(4)): Covered as described in 6.2.1, 6.2.2, and 6.2.3. In addition, professional services rendered by a physician, surgeon, or doctor of dental surgery for treatment of a fractured jaw or other accidental injury to sound natural teeth and gums are covered.

Organ and tissue transplants are not covered.

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)): Covered as described for other services described in this Section (6.2).

6.2.6.

Prescription drugs (Section 2110(a)(6)): Coverage includes drugs prescribed by a practitioner acting within the scope of his or her practice. Chemotherapy drugs approved for use in humans by the U.S. Food and Drug Administration, vaccines, and drugs needed after an organ or tissue transplant are covered.

Birth control contraceptives are not covered.

The contractor must use the Medicaid formulary if it chooses to employ a formulary and must notify enrollees and providers which prescription drugs are covered.

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Approval Date: 33 Prescribed diabetic equipment and supplies including insulin, syringes, injection aids, devices for self-monitoring of glucose levels (including those for the visually impaired), test strips, visual reading and urine test strips, one insulin pump for the warranty period, accessories to insulin pumps, glucagons emergency kits, and one prescriptive oral agent for controlling blood sugar levels for each class of drug approved by the United States Food and Drug Administration are covered as a prescription drug.

Prescription prenatal vitamins, and medical foods for the treatment of inborn errors of metabolism that involve amino acid, carbohydrate, and fat metabolism, and for which medically standard methods of diagnosis, treatment, and monitoring exist, are covered.

Food supplements and vitamins (with the exception of prenatal vitamins), whether or not requiring a written prescription, are not covered.

6.2.7.

Over-the-counter medications (Section 2110(a)(7))

6.2.8.

Laboratory and radiological services (Section 2110(a)(8)):

Coverage includes imaging and laboratory services for diagnostic or therapeutic purposes due to accident, illness, or medical condition that are not described elsewhere in this section (6.2).

X-ray, radium, and radioactive isotope therapy are covered.

6.2.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9)):

Prenatal care is covered as described for other medical conditions in this Section (6.2). Pre-pregnancy family planning services are covered. Birth control contraceptives are not covered.

Medical or surgical treatment to reverse surgically induced infertility; fertility enhancing procedures beyond diagnosis; and sex change operations are not covered.

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Approval Date: 34 6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)):

HMK has removed financial and treatment limitations on inpatient mental health benefits. Enrollees receive the following mental health benefits: prescription drugs, outpatient and inpatient services as outlined in this section and 6.2.11. There are no maximum annual or lifetime limits on covered services.

6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11):

There are no maximum annual or lifetime limits on covered and medically necessary mental health benefits.

Effective July 1, 2010 the State is providing mental health benefits in a manner equal to medical benefits. Extended mental health benefits for children with a serious emotional disturbance (SED) are in addition to the basic mental health benefits HMK covers. These extended mental health services are community or home-based services that do not have a medical counterpart. Enrollees who have a serious emotional disturbance as determined by a department or department-contracted licensed mental health professional may receive extended mental health services beyond coverage provided under the basic plan. Extended mental health benefits include:

1) Community Based Psychiatric Rehabilitation and Support, and 2) Respite care.

6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)):

Eyeglasses are provided by a bulk-purchasing contractor and reimbursed directly by the State of Montana, Department of

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 35 Public Health and Human Services. Eyeglasses are not paid by the TPA Contractor.

Audiological Services—Hearing exams, including newborn hearing screens in a hospital or outpatient setting, are covered. Coverage includes assessment and diagnosis. Hearing aids are covered.

6.2.13.

Disposable medical supplies (Section 2110(a)(13))

6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14))

6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15))

6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16):

6.2.17.

Dental services (Section 2110(a)(17)):

6.2.-D The State will provide dental coverage to children through one of

the following. Dental services provided to children eligible for

dental-only supplemental services must receive the same dental

services as provided to otherwise eligible CHIP children (Section

2103(a)(5)):

6.2.1.-D ∼ State Specific Dental Benefit Package. The State assures

dental services represented by the following categories of

common dental terminology (CDT) codes are included in

the dental benefits:

1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes:

D0100-D0999) (must follow periodicity schedule)

2. Preventive (i.e., dental prophylaxis, topical fluoride

treatments, sealants) (CDT codes: D1000-D1999) (must

follow periodicity schedule)

3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-

D2999)

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 36

4. Endodontic (i.e., root canals) (CDT codes: D3000-

D3999)

5. Periodontic (treatment of gum disease) (CDT codes:

D4000-D4999)

6. Prosthodontic (dentures) (CDT codes: D5000-D5899,

D5900-D5999, and D6200-D6999)

7. Oral and Maxillofacial Surgery (i.e., extractions of teeth

and other oral surgical procedures) (CDT codes: D7000-

D7999)

8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999)

9. Emergency Dental Services

6.2.1.2-D ∼ Periodicity Schedule. The State has adopted the

following periodicity schedule:

State-developed Medicaid-specific

American Academy of Pediatric Dentistry

Other Nationally recognized periodicity schedule

Other (description attached)

6.2.2-D ∼ Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410,

and 42 CFR 457.420)

6.2.2.1.-D ∼ FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i))

(If checked, attach copy of the dental supplemental plan

benefits description and the applicable CDT codes. If the

State chooses to provide supplemental services, please

also attach a description of the services and applicable

CDT codes)

6.2.2.2-D ∼ State employee coverage; (Section 2103(c)(5)(C)(ii)) (If

checked, identify the plan and attach a copy of the

benefits description and the applicable CDT codes. If the

State chooses to provide supplemental services, please

also attach a description of the services and applicable

CDT codes):

HMK, in accordance with CHIPRA, will provide dental benefits using the State of Montana employee and

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 37 dependent dental benefit plan as a benchmark. (See Dental Attachment A and Dental Attachment B)

6.2.2.3.-D∼ HMO with largest insured commercial enrollment

(Section2103(c)(5)(C)(iii)) (If checked, identify the

plan and attach a copy of the benefits description and the

applicable CDT codes. If the State chooses to provide

supplemental services, please also attach a description of

the services and applicable CDT codes)

The HMK ―basic‖ dental benefit is increasing from $412

per year to $1,412 per year. In addition, HMK-enrolled

children are eligible for the ―extended dental benefit‖ if

they have significant dental needs beyond those covered I

in the basic dental plan. These children may receive

additional services through the Extended Dental Plan

(EDP) if a dental provider determines a child has

significant dental needs which exceed the basic dental

plan maximum payment. The provider may submit a prior

authorization request for EDP coverage which must

include the projected treatment plan and costs. DPHHS

staff will review the provider’s request and notify the

provider and the family if the child is eligible for EDP

coverage and sufficient funds are available. EDP covers

the same type of services as the basic plan. For example,

since restorations (―fillings‖) are covered by the basic

plan, additional restorations may be approved under the

EDP.

Each enrollee who is determined eligible for extended

benefits may receive (in addition to the basic benefit) up

to $1,176.47 in dental services in the benefit year

(October 1 through September 30). Since these services

are reimbursed at 85% of billed charges, the maximum

payment for EDP services is $1,000 per child per benefit

year based upon available funds.

An HMK-enrolled child may receive a combination of

dental benefits totaling up to $2,588.47 (basic = $1,412 +

EDP = $1,176.47) in services in a benefit year. The

maximum reimbursement to the dental provider would be

$2,200 (basic = $1,200 + EDP = $1,000).

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 38

There is no cost sharing for dental services for either

basic or EDP benefits. The EDP provides additional

dental benefits administered with a capped budget that

exceed the benefits available under the State employee

(benchmark) dental plan.

HMK/CHIP is in compliance with CHIPRA requirements

as defined in the CMS SHO letter dated October 7, 2009

and with the selection of 6.2.2.2-D in the dental template

section of this SPA. Medically-related dental emergencies

are reimbursable under medical benefits, defined in 6.2.4

of the existing SPA.

6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)):

HMK benefits include inpatient substance abuse treatment and residential substance abuse treatment services. There are no maximum lifetime or annual limits for covered services.

6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)):

HMK benefits include outpatient substance abuse treatment services. There are no maximum lifetime or annual limits for covered services.

6.2.20.

Case management services (Section 2110(a)(20))

6.2.21.

Care coordination services (Section 2110(a)(21))

6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)):

DPHHS requires prior authorization for occupational, speech and physical therapy services.

6.2.23.

Hospice care (Section 2110(a)(23))

6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 39 instructions) (Section 2110(a)(24)):

Vision Services and Medical Eye Care—Services for the medical treatment of diseases or injury to the eye by a licensed physician or optometrist working within the scope of his or her license are covered. Vision exams and eyeglass dispensing fees are covered.

6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.26.

Medical transportation (Section 2110(a)(26))

The department will cover emergency ambulance services.

6.2.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27))

6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28)):

Nurse Advice Line access to health information and advice twenty-four hours a day seven days a week is a covered benefit.

6.3. The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR

6.3.2.

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4. Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 40 must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2.

Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 41 6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a))

6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b))

6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

6.4.3. Additional state Options for Providing Premium Assistance A state may elect to offer a premium assistance subsidy for qualified employer-sponsored coverage, as defined in section 2105(c)(10)(B), to all targeted low-income children who are eligible for child health assistance under the plan and have access to such coverage. No subsidy shall be provided to a targeted low-income child (or the child’s parent) unless the child voluntarily elects to receive such a subsidy. (section 2105(c)(10)(A)). Does the State provide this option to targeted low-income children?

Yes

No

6.4.3.1. Qualified Employer-Sponsored Coverage and Premium

Assistance Subsidy

6.4.3.1.1. Please provide an assurance that the qualified employer-sponsored insurance meets the definition of qualified employer-sponsored coverage as defined in section 2105(c)(10)(B), and that the

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 42 premium assistance subsidy meets the definition of premium assistance subsidy as defined in 2105(c)(10)(/c).

6.4.3.1.2. Please describe whether the State is providing the premium assistance subsidy as reimbursement to an employee or for out-of-pocket expenditures or directly to the employee’s employer.

6.4.3.2 Supplemental Coverage for Benefits and Cost Sharing Protections Provided under the State Child Health Plan.

6.4.3.2.1. If the State is providing premium assistance for

qualified employer-sponsored coverage, as defined

in section 2105(c)(10)(E)(i), please provide an

assurance that the State is providing for each

targeted low-income child enrolled in such

coverage, supplemental coverage consisting of all

items or services that are not covered or are only

partially covered, under the qualified employer-

sponsored coverage consistent with 2103(a) and

cost sharing protections consistent with section

2103(e).

6.4.3.2.2. Please describe whether these benefits are being

provided through the employer or by the State

providing wraparound benefits.

6.4.3.2.3. If the State is providing premium assistance for

benchmark or benchmark-equivalent coverage,

check here to indicate that the State will ensure

that such group health plans or health insurance

coverage offered through an employer will be

certified by an actuary as coverage that is

equivalent to a benchmark equivalent coverage

that meets the requirements of section 2103(a)(2).

6.4.3.3. Application of Waiting Period Imposed Under State Plan: States are required to apply the same waiting period to premium assistance as is applied to direct coverage for children under their CHIP State plan, as specified in section 2105(c)(10)(F).

6.4.3.3.1. Please provide an assurance that the

waiting period for children in premium assistance is

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 43

the same as for those children in direct coverage (if

State has a waiting period in place for children in

direct CHIP coverage).

6.4.3.4. Opt-Out and Outreach, Education, and Enrollment Assistance

6.4.3.4.1. Please describe the State’s process for ensuring

parents are permitted to disenroll their child from

qualified employer-sponsored coverage and to

enroll in CHIP effective on the first day of any

month for which the child is eligible for such

assistance and in a manner that ensures continuity

of coverage for the child (section 2105(c)(10)(G)).

6.4.3.4.2. Please describe the State’s outreach, education,

and enrollment efforts related to premium

assistance programs, as required under section

2102(c)(3). How does the State inform families of

the subsidies? What are the specific significant

resources the State intends to apply to educate

employers about the availability of premium

assistance subsidies under the State child health

plan? (section 2102(c))

6.4.3.5 Purchasing Pool: A State may establish an employer-family premium assistance purchasing pool and may provide a premium assistance subsidy for enrollment in coverage made available through this pool )section 2105(c)(10)(I). Does the State provide this option?

Yes

No

6.4.3.5.1 Please describe the plan to establish an employer-

family premium assistance purchasing pool.

6.4.3.5.2 Please provide an assurance that employers who

are eligible to participate: 1) have less than 250

employees; 2) have at least one employee who is

a pregnant woman eligible for CHIP or a member

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 44

of a family that has at least one child eligible under

the State’s CHIP plan.

6.4.3.5.3 Please provide an assurance that the State will not

claim for any administrative expenditures

attributable to the establishment or operation of

such a pool except to the extent such payment

would otherwise be permitted under this title.

6.4.3.6. Notice of Availability of Premium Assistance: Please describe the procedures that assures that if a State provides premium assistance subsidies under this section, it must: 1) provide as part of the application and enrollment process, information describing the availability of premium assistance and how to elect to obtain a subsidy; and 2) establish other procedures to ensure that parents are fully informed of the choices for child health assistance or through the receipt of premium assistance subsidies (section 2105(c)(10)(K)).

6.4.3.6.1. Please provide an assurance that the State

includes information about premium assistance

on the CHIP application or enrollment form.

Section 7. Quality and Appropriateness of Care

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.)

7.1.1.

Quality standards

7.1.2.

Performance measurement

7.1.3.

Information strategies

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 45 7.1.4.

Quality improvement strategies

DPHHS uses HEDIS performance measurements to evaluate care effectiveness for enrollees.

HMK Plus and HMK management staff are interested in assuring both programs adhere to continuity and comparability between the measures used. HMK Plus currently uses HEDIS measures for its Primary Care Case Management Program (PASSPORT). The contract with the TPA Contractor requires them to collect and report HEDIS data and utilization reports. The following is a list of required measures and required reports:

HEDIS

 Childhood immunization status  Adolescent immunization status  Children’s access to primary care providers  Well-child visits in the first fifteen months of life  Well-child visits in the third, fourth, fifth, and sixth year of life  Adolescent well care visits  Use of appropriate medications for children with asthma

Utilization Reports  Healthcare Experience Profile  Plan Experience Report  Claims Lag Report  Summary Experience Report  Summary Savings Report  Summary Savings by Service Type  Statistical Analysis  Variance Analysis  Claims by Enrollment Demographics  Third Party Drug Claims by Therapeutic Group  Catastrophic Illness Analysis  Claims Distribution Analysis  Quality of Care – Indicators  Quality of Care - Complexity  Medical Claims Cost Analysis  Inpatient Utilization for Top 25 Hospitals  Inpatient Utilization for Top 25 Physicians  Inpatient Utilization by Principal Disease Category

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 46  Utilization for Top 20 Inpatient Surgeries by Frequency  Top 20 Inpatient Surgeries by Cost  Outpatient Utilization by Service Type  Impatient Utilization by Major Diagnostic Category  Outpatient Utilization by major Diagnostic Category  Utilization for Top 15 Outpatient Surgeries

DPHHS uses these performance measures, HEDIS, utilization and complaint data to evaluate the TPA Contractor’s performance.

Consumer education tools ensure enrollees have adequate information regarding eligibility and enrollment. DPHHS staff approves the member handbook to assure that benefit, provider network, and complaint procedures are communicated effectively. Other consumer education materials are developed as part of DPHHS’s quality assurance program and based on performance measures’ results.

Newsletters are sent to families with enrolled children or children on the waiting list. The newsletters are sent when policy changes may impact families to provide information about benefits and encourage the use of preventive health services.

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a)):

DPHHS staff monitors the following HEDIS reports to evaluate and assure access to preventive care:

 Childhood immunization status  Adolescent immunization status  Children’s access to primary care providers  Well-baby visits in the first fifteen months of life  Well-child visits in the third, fourth, fifth, and sixth year of life  Adolescent well care visits  Use of appropriate medications for children with asthma  Mental Health Utilization – Percentage of children receiving inpatient, intermediate care and ambulatory services  Chemical Dependency Utilization – Percentage of children receiving inpatient, intermediate and ambulatory services

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 47  Ambulatory care – Emergency department visits  Appropriate treatment of children with upper respiratory infection  Appropriate testing for children with pharyngitis

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

Access Assurance for Care Delivered through Insurers and the CHIP Provider Network:

Access to services is measured by evaluating and monitoring the adequacy of provider networks and by analyzing the results of complaint data and performance measures. Provider network analysis looks at the number and types of physicians, hospitals and allied health providers of health care for children, their locations, and their hours. The TPA contractor is required to produce a provider network access plan. DPHHS staff evaluates this network as described in Section 3.1. DPHHS staff also annually evaluates access-related performance measures such as access-related complaints and access to primary care physicians (HEDIS).

The TPA contractor submits information each month about the number, type and geographic distribution of network providers. This information is posted on the program’s website.

Emergency Services Access: The contract with the TPA Contractor specifies prior authorization for emergency medical conditions is not required. An emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

 placing the health of the child (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,  serious impairment to bodily functions, or  serious dysfunction of any bodily organ or part.

Access to emergency services is monitored by analysis of complaint data and utilization data.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 48 7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c)) The DPHHS contract with the TPA contractor requires medically appropriate second opinions, which may include major diagnoses or courses of treatment, as a covered benefit. The TPA Contractor is also required to have a system to assure prompt referrals for medically necessary, specialty, secondary, and tertiary care.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

Decisions related to the prior authorization of health services are completed in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. The TPA Contractor aims for a turnaround time of five (5) days.

Section 8. Cost Sharing and Payment (Section 2103(e))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1.

YES

8.1.2. NO, skip to question 8.8.

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

8.2.1. Premiums: NONE

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 49 8.2.2. Deductibles: NONE

8.2.3. Coinsurance; NONE

Copayments: A. No co-payment is assessed for families with household incomes equal to or less than 100% of the federal poverty level. B. No copayment is assessed for families with at least one enrollee who is a Native American or Native Alaskan. C. Copayments do not exceed the maximum allowable cost- sharing charges in accordance with 42 CFR Part 457.555. D. Copayments for inpatient hospital services are in accordance with 42 CFR 457.555 (b) E. For families with household incomes above 100% of the federal poverty level, the following co-payments will apply:

Benefit Co-payment Inpatient hospital services (includes hospitalization for physical, mental and substance abuse reasons) $25 per visit Emergency ambulance services $25 per service Emergency room visit $5 per visit Outpatient hospital visit (includes outpatient treatment for physical, mental, and substance abuse reasons. Excludes outpatient visits for X-ray or laboratory services only) $5 per visit Physician, naturopathic physician, mid-level practitioner, advanced-practice registered nurse, optometrist, audiologist, mental health professional, or substance abuse counselor services (excludes dental, pathology, radiology, or anesthesiology services) $3 per visit Outpatient prescription drugs—generic $3 per prescription Outpatient prescription drugs—brand-name $5 per prescription Mail Order prescription drugs-generic (3 mo. supply) $6 per prescription Mail Order prescription drugs-brand name (3 mo. supply) $10 per prescription

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 50 No co-payment applies to well-baby or well-child care, including age-appropriate immunizations. Co-payments are capped at $215 per family per benefit year (October 1 – September 30) for families with incomes up to 250% FPL. When the $215 maximum copayment has been met, the TPA contractor issues new member cards indicating no copayment is required for the remainder of the benefit year.

8.2.4. Other: NONE

8.3. Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

A description of cost sharing (including the cumulative maximum) is contained in the outreach and educational materials which are distributed to the general public. This information is contained in the Member Handbook which is updated and distributed to all members annually. The copayment requirement, if applicable, is indicated on the ID cards families receive from the TPA Contractor. If a member’s copayment requirement changes, the TPA contractor issues a new ID card which reflects the change.

DPHHS informs enrollees, applicants, providers and the general public of changes to cost sharing by revisions to the above-mentioned documents and revision of the Administrative Rules of Montana (ARM).

Prior public notice of proposed co-payment changes are provided in a form and manner provided under applicable State law. Public notice is published prior to the requested effective date of the change.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530)

8.4.2.

No cost-sharing applies to well-baby and well-child care,

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 51 including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520)

8.4.3

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Enrollees in the HMK coverage group have co-payments if their family income is greater than 100% of FPL. The insurance card each child receives from the TPA Contractor indicates whether or not a child has a co-payment when services are used. The TPA Contractor tracks the co-payments charged to the family. When the $215 annual family maximum is reached, the TPA Contractor sends the family a letter indicating that the maximum co-payment has been met and a co-payment is not required for the remainder of the benefit year. The TPA contractor issues new ID cards which indicate no copayment is required for the remainder of the benefit year. Enrollment materials notify families how to recoup any excess co-payments they have paid. Families charged more than $215 in co-payments must submit co-payment receipts to DPHHS in order to be reimbursed for copayments they paid above the maximum. DPHHS reimburses the family for any co-payment paid above the $215 maximum payment.

Enrollees in the HMK Plus coverage group do not have a co-payment requirement.

8.6. Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

The DPHHS contract with the TPA Contractor requires that families with Native American or Alaska Native children have no co-payment for services. ID cards for these children state that co-payments are not required.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 52 No enrollees in the HMK Plus coverage group, regardless of race, have a co- payment requirement.

8.7. Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

Not Applicable - Enrollees are not disenrolled for non-payment for cost sharing charges.

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

Not Applicable - Enrollees are not disenrolled for non-payment for cost sharing charges.

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

Not Applicable - Enrollees are not disenrolled for non-payment for cost sharing charges.

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

Enrollees are not disenrolled for non-payment for cost sharing charges.

A Fair Hearing is granted to any enrollee or guardian when an adverse action results in disenrollment. (refer to Section 12.1 for additional detail.)

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 53 8.8. The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220)

8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5)

8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under this title.

(Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5))

8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475)

8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

DPHHS’s strategic objectives are to:

1. Improve the health status of children with a focus on preventive and

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Approval Date: 54 early primary care treatment. 2. Increase the number of children who are enrolled in the Healthy Montana Kids Plan. 3. Prevent ―crowd out‖ of employer coverage. 4. Coordinate and consolidate with other health care programs providing services to children to create a seamless health care delivery system for low-income children.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

1. Improve health status of children with a focus on preventive and early primary care treatment. Performance goal: 96% of children 12-24 months of age will receive preventive or primary care treatment each year 2. Increase the number of children who are enrolled in the Healthy Montana Kids Plan. Performance goal: Enroll 29,000 additional children in the Healthy Montana Kids Plan. 3. Prevent ―crowd-out‖ of employer coverage. Performance Goal: Maintain the proportion of children < 250% of federal poverty who are covered under an employer-based plan taking into account decrease due to health care costs or a downturn in the economy. 4. Coordinate and consolidate with other health care programs providing services to children to create a seamless health care delivery system for low-income children.

Performance Goal: Coordinate with the Title V Children’s Special Health Services program and the Children’s Mental Health Services Plan to ensure 95% of eligible children who need care beyond what is offered under HMK coverage group are referred to these programs.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

Objective One: Improve health status of children with a focus on preventive and early primary treatment: The TPA Contractor is required to collect and report HEDIS data and utilization data. The Department of Public Health and Human Services will use this data to measure success of the plan in establishing baseline data and reaching the performance goals regarding immunization and well-child care.

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Approval Date: 55 DPHHS conducts an Enrollee Satisfaction Survey. Surveys are mailed to randomly selected current enrollees. The purpose of the survey is to assess enrollees’ satisfaction with the program. The survey measures enrollees’ perception of services received from providers and program staff. In addition, it measures the use and effectiveness of program materials.

Objective Two: Decrease the proportion of children in Montana who are uninsured and reduce financial barriers to affordable health care coverage: Performance goals under this objective are measured based on the decrease in the number of uninsured children in families with incomes 250% of the federal poverty level compared with the number uninsured before the state plan’s effective date. First, baseline numbers of uninsured children will be calculated from a three-year average of the 2005, 2006, and 2007 March supplement to the Current Population Survey produced by the Bureau of the Census. New estimates of uninsured children will be calculated as more current data become available and will be used to compare trends from year to year.

Objective Three: Prevent “crowd-out” of employer coverage: Performance goals under this objective will be measured based on the proportion of children at or below 250% of federal poverty who are covered under an employer based plan taking into account decreases due to increases in health care costs or a downturn in the economy. The proportion of children covered under the employer-based plan will be evaluated, and analysis will be conducted to test for evidence of ―crowd-out‖. The baseline for comparison will be obtained from a 3 year average of the 2005, 2006, and 2007 March Current Population Survey.

In addition, the eligibility determination process includes questions relating to

parents’ access to and coverage by health insurance. This allows the state to

track the number of children who have access to employer-based coverage,

monitor that children enrolling in the program are not dropping affordable

employment based coverage, and/or apply a three month insurance delay wait

period if the children do not meet one of the state’s exceptions.

Objective Four: Coordinate and consolidate with other health care programs providing services to children to create a seamless health care delivery system for low-income children: Performance goals under this objective are based on the enrollment of children receiving care through the Children’s Mental Health Services Plan, HMK Plus, Health Insurance for Montana University System Dependent Care Premium Waiver Program, and Insure Montana. DPHHS staff provides information about Community Health Centers, Urban Indian Clinics, Migrant

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Approval Date: 56 Health Clinics, National Health Service Corps sites and Montana Youth Care. DPHHS staff makes referrals to Children’s Special Health Services, Children’s Mental Health Services Plan and other health care programs for children.

The Healthy Montana Kids Plan (HMK) will create a seamless health care delivery system for CHIP-funded and Medicaid-funded services provided by the Healthy Montana Kids Plan. The new computerized eligibility determination system for DPHHS health and social service programs will assist the department to meet this objective.

Objective Five: Increase the enrollment of currently eligible, but not participating, children in HMK Plus: Extensive outreach efforts including Community Enrollment Partners will be implemented to increase enrollment of currently eligible, but un-enrolled children.

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4))

9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid.

9.3.2.

The reduction in the percentage of uninsured children.

9.3.3.

The increase in the percentage of children with a usual source of care.

9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state.

9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19.

9.3.6.

Other child appropriate measurement set. List or describe the set used.

9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as:

9.3.7.1. Immunizations

9.3.7.2. Well childcare

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Approval Date: 57 9.3.7.3. Adolescent well visits

9.3.7.4. Satisfaction with care

9.3.7.5. Mental health

9.3.7.6. Dental care

9.3.7.7. Other, please list:

Children’s access to primary care providers

9.3.8.

Performance measures for special targeted populations.

9.4.

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

DPHHS completes the annual assessments and evaluations required in Section 2108(a). The Annual Report includes an assessment of the operation of the program and its progress toward meeting its strategic objectives and performance goals.

DPHHS completes and submits quarterly statistical reports through the SCHIP Statistical Enrollment Data System (SEDS). These statistics of unduplicated ever-enrolled children is reported by gender, race and ethnicity.

9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8. The state assures, to the extent they apply, that the following provisions of the

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 58 Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards)

9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment)

9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes)

9.8.4.

Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b)):

Since implementation, DPHHS advisory councils have provided important advice, comments, and recommendations. When DPHHS proposes changes to the Administrative Rules of Montana notice is given and a public hearing is scheduled to allow interested parties to comment and provide input.

In November, 2008, a citizens’ initiative, Montana Initiative I-155, Healthy Montana Kids Plan Act was approved by 70% of all voters. The HMK Plan Act increases the income eligibility guideline for HMK (formerly known as CHIP) enrollees to 250% of the FPL. Included in HMK Plan Act is the elimination of the Medicaid asset test for children. The department also is implementing a CHIP-funded/Medicaid Expansion Program for children ages 6-18 years of age whose family incomes are at or below 133% of the FPL.

Other provisions in the Healthy Montana Kids Act include the following:  Enrollment Partners  Increase the ―insurance delay period‖ from one month to three months  Coordinate enrollment and application for CHIP-funded and Medicaid-funded benefits  Presumptive eligibility  Premium assistance  Assistance to employers to implement Premium Only Health Benefit Plans (―Section 125 Plans‖)

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 59 Legislative Input:  During the 2009 legislative session the legislature appropriated State Special Revenue funds as the state match for the HMK initiative described above.  DPHHS provides quarterly program updates to legislative interim committees.

Meetings with Interested Parties:

DPHHS staff meets with other statewide association advisory boards and interested parties, including: Montana Hospital Association, Primary Care Association, Health Advisory Council, Public Health Association, Family Planning State Council, Montana Council for Maternal and Child Health, Montana Children’s Alliance, Children’s Committee of the Mental Health Association, Head Start, Public Health and School Nurses, Governor’s Council on Children and Families, the Montana Association of Counties, Human Services Committee, Montana People’s Action, Working for Equality and Economic Liberation, Montana Migrant Council, and the Native American Advisory Council. At the request of several organizations, a program update is provided at each meeting, allowing time for questions, comments, and problem solving.

9.9.-APA Describe the process used by the State to accomplish involvement of the public in the design and implementation of the plan and the method for ensuring ongoing public involvement. (section 2107(c) and 42 CFR 457.120(a) and (b)).

The department revised the HMK state rules in accordance with the Montana Administrative Rules process. This process includes letters to interested parties, a public comment period and a public hearing.

Note: Notice to Native American information is reported on the next page (e.g. Tribal Chairmen, Tribal Health Directors, Urban Indian Center Directors and Indian Health Service.)

9.9.1 Describe the process used by the state to ensure interaction with Indian

Tribes and organizations in the state on the development and

implementation of the procedures required in 42 CFR 457.125.

(Section 2107(c)) (42CFR 457.120(c))

DPHHS works directly with tribes, the Indian Health Service, Tribal Health Services, Bureau of Indian Affairs, Urban Indian Clinics and the Governor’s Native American Advisory Council to inform Native Americans in Montana about the program. DPHHS staff provides

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 60 annual updates and training at each of the seven Montana reservations and five Urban Indian Clinics. In addition, DPHHS staff participates in the annual CMS/IHS Medicare, Medicaid and CHIP training.

DPHHS staff presented a web-based seminar to Tribal Council Chairpersons, IHS and Tribal Health Directors, Urban Indian Clinic Directors and IHS administrators regarding the Healthy Montana Kids Plan. The department invited comment from all Tribal Chairpersons and Presidents, Tribal Health Directors, IHS Directors and Urban Center Directors regarding the HMK State Plan amendments. The department provided a draft of State Plan Amendments number 7 and number 8 on the department’s website.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in §457.65(b) through (d).

Prior public notice of proposed changes is provided in a form and manner provided under applicable State law. Public notice will be published prior to the requested effective date of the change.

9.10. Provide a one year projected budget. (Section 2107(d)) (42CFR 457.140)

The budget must describe:  Planned use of funds, including :  Projected amount to be spent on health services;  Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and  Assumptions on which the budget is based, including cost per child and expected enrollment.  Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

States must include a separate budget line item to indicate the cost of

providing coverage to premium assistance children.

Please see attached FY2011 projected budget. SCHIP Budget FFY 2011

Federal Fiscal Year Costs Enhanced FMAP rate 76.77%

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Approval Date: 61 Benefit Costs

Insurance payments

Managed care 0 Fee for Service (FFS) 89,332,788 Total Benefit Costs 89,332,788 (Offsetting beneficiary cost sharing payments) 0 Net Benefit Costs 89,332,788

Administration Costs

Personnel 1,982,930 General administration 1,024,375 Contractors/Brokers (e.g., enrollment contractors) 0 Claims Processing 1,800,233 Outreach/marketing costs 502,200 Other - Indirect Cost 975,322 Total Administration Costs 6,285,060 10% Administrative Cost Ceiling 9,967,585

Federal Share (multiplied by FMAP @ 76.77%) 73,405,822 State Share - (23.23%) 22,212,026 TOTAL PROGRAM COSTS 95,617,848

Enrollment fee, deductible and enrollee premium are not required. Enrollee cost sharing is netted out of the total benefit costs.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 62 Budget Assumptions

Benefits Montana contracts with Blue Cross Blue Shield of Montana (BCBSMT) for third party administrative services (TPA) for medical and pharmacy benefits. The department provides eyeglasses, dental services and community based psychiatric (CBPRS) services on a fee for service basis.

The estimated monthly enrollment is 39,172 for FY 2011. The cost per member per month includes the separate CHIP program and the CHIP- Medicaid Expansion Program and the projected benefit cost is $204/month.

The income eligibility guidelines for the HMK coverage group (CHIP) changed from 175% to 250% FPL effective October 1, 2009. The increase in the projected expenditures reflects claims costs associated with the increased enrollment of children in the HMK coverage group and the CHIP Medicaid expansion program.

Note: Projected budget costs include costs for SPA #7 (Coverage for eligible children of State of Montana and Montana University System employees.)

Administration Department staff is responsible for program management including assessment, policies and procedures development, department and community programs’ coordination, budgeting, eligibility determination, enrollment, contract monitoring, outreach and oversight.

Claims are paid on a fee for service (FFS) basis through a third party administrative (TPA) contract. There was no change in cost-sharing.

Funding Tobacco settlement funds, tobacco tax and State Special Revenue Funds are used as the non-Federal share of plan expenditures. The State Special Revenue Fund is composed of, but is not limited to fees collected by the Montana Insurance Commissioner from each insurer applying for or annually renewing a certificate of authority to conduct the business of insurance in Montana.

Montana’s State Legislature gave the Department of Public Health and Human Services authority to match federal dollars with private donations. Montana will, upon CMS approval, use private donations when available. Background information on donors will be submitted to CMS, as required, prior to the

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Approval Date: 63 expenditure of donated funds. Montana ensures that donations used as matching funds adhere to requirements stated in 42 CFR Subpart B (433.51 – 433.74). Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1.

The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2.

The state assures it will comply with future reporting

requirements as they are developed. (42CFR 457.710(e))

10.3.

The state assures that it will comply with all applicable Federal

laws and regulations, including but not limited to Federal grant

requirements and Federal reporting requirements.

10.3-D Specify that the State agrees to submit yearly the

approved dental benefit package and to submit

quarterly the required information on dental providers

in the State to the Health Resources and Services

Administration for posting on the Insure Kids Now!

Web site.

Section 11. Program Integrity (Section 2101(a))

Check here if the state elects to use funds provided under Title XXI only to

provide expanded eligibility under the state’s Medicaid plan, and continue to

Section 12.

11.1.

The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 64 a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9)

11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents)

11.2.2.

Section 1124 (relating to disclosure of ownership and related information)

11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals)

11.2.4.

Section 1128A (relating to civil monetary penalties)

11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.

Section 1128E (relating to the National health care fraud and abuse data collection program)

Section 12. Applicant and Enrollee Protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to

provide expanded eligibility under the state’s Medicaid plan.

12.1. Eligibility and Enrollment Matters

Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

A Social Security Number is required for a child who applies for benefits. Enrollment is not be denied or delayed to an otherwise eligible child pending issuance of a child’s SSN. The program restricts the use of disclosure of information concerning applicants and enrollees to purposes directly connected with administration of the plan.

An applicant or enrollee has an opportunity for review of eligibility and enrollment matters. Such matters include the following: denial of eligibility, failure to make a timely determination of eligibility and termination of enrollment.

The review process for eligibility and enrollment matters is conducted by the DPHHS Office of Fair Hearings, Quality Assurance Division, in accordance with the program’s Fair Hearing Policy. Families of children who are applying for or are enrolled in the program are notified of their right to Fair Hearing.

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Approval Date: 65

A Fair Hearing is granted to the following individuals: 1) applicant, parent or guardian who requests a hearing because his or her application is denied, and 2) an enrollee, parent or guardian when an adverse action results in disenrollment. The hearing request must be submitted in writing within 90 days of the Department’s action notice.

A hearing request is defined as a clear expression by the applicant, or authorized representative that he or she wants the opportunity to present the case to a higher authority.

The Department is responsible to assure an applicant’s right to due process and hearing. Hearings are conducted by an impartial official of the Department who is not directly involved in the initial determination of the action in question.

The Hearing Officer’s decision is made within 90 days of the hearing’s conclusion. The Hearing Officer’s decision may be appealed appealed to the Board of Public Assistance within 15 days of the mailing of the Fair Hearing decision. No action is taken on the case until the 15-day limit for appeal passes. There is a hearing record compiled for each case and it is available to the applicant at a reasonable time for viewing and copying.

12.2. Health Services Matters

Please describe the review process for health services matters that comply with 42 CFR 457.1120.

An applicant or enrollee has an opportunity for a review of health services matters. The TPA contractor’s complaint resolution policy: An enrollee may call or write to the plan to ask questions, ask for a review of a decision or make a verbal complaint. The TPA Contractor will respond to telephone inquiries within 10 working days. The TPA Contractor will acknowledge a written complaint within 10 days of receipt and send a written response or decision on the complaint within 45 days of receipt. An enrollee may make a appeal if an unfavorable decision is received from the TPA Contractor. Within 90 days of receiving a letter from the TPA Contractor about a decision, the enrollee may submit a written complaint to Montana DPHHS Office of Fair Hearings.

A hearing request is defined as a clear expression by the applicant, or authorized representative that he or she wants the opportunity to present the case to a higher authority.

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Approval Date: 66 The Department is responsible to assure an applicant’s right to due process and hearing. Hearings are conducted by an impartial official of the Department who is not directly involved in the initial determination of the action in question.

The Hearing Officer’s decision is made within 90 days the hearing’s conclusion. The Hearing Officer’s decision may be appealed to the Board of Public Assistance within 15 days the mailing the Fair Hearing decision. No action is taken on the case until the 15-day limit for appeal passes. There is a hearing record compiled for each case and it is available to the applicant at a reasonable time for viewing and copying.

This information is included in the Member Handbook that is provided when children are enrolled. 12.3. Premium Assistance Programs

If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

MONTANA TITLE XXI PROGRAM FACT SHEET

Name of Plan:

Montana's Children's Health Insurance

Plan

Date of Plan Submitted:

April 13, 1998 Date Plan Approved:

September 11, 1998 State Plan Effective Date:

January 1, 1998

Date First Amendment Submitted:

December 27, 1999 Date First Amendment Approved:

October 6, 2000 First Amendment Effective Date:

June 1, 2000

Date Second Amendment Submitted:

July 1, 2002 Date Second Amendment Approved:

September 27, 2002 Second Amendment Effective Date:

July 1, 2002

Date Third Amendment Submitted:

March 6, 2006 Date Third Amendment Approved:

July 13, 2006 Third Amendment Effective Date:

October 1, 2005

Date Fourth Amendment Submitted:

July 16, 2007 Date Fourth Amendment Approved:

October 5, 2007 Fourth Amendment Effective Date:

July 1, 2007, October 1, 2006,

October 1, 2007

Date Fifth Amendment Submitted:

May 1, 2009 Date Fifth Amendment Approved:

December 9, 2009 Fifth Amendment Effective Date:

October 1, 2009

Date Sixth Amendment Submitted

July 31, 2009 Date Sixth Amendment Approved

December 18, 2009

Sixth Amendment Effective Date

October 1, 2009

Background

• On April 13, 1998, Montana submitted a Title XXI State plan to expand coverage to children through a benchmark-equivalent benefit package. The State proposed to provide coverage for children under the age of 19 and with family income at or below 150 percent of the Federal Poverty Level (FPL).

Amendments

• On December 27, 1999, Montana submitted its first State plan amendment, implementing the following major programmatic changes: an enrollment cap of

10,100 children implemented on January 1, 2001; the adoption of a universal application form; modification of definition of countable income; elimination of the annual enrollment fee; exclude coverage for contraceptives; the addition of a $350 dental benefit and an eyeglass benefit; increase in the annual maximum copayment from $200 to $215; and, the elimination of cost-sharing for the Native American children enrolled in CHIP.

• Montana submitted its second amendment on July 1, 2002. This amendment updated and amends the CHIP state plan to indicate the State’s compliance with the final CHIP regulations. This amendment reduces mental health benefits. They will still include inpatient and outpatient mental health services and prescription drugs.

• Montana submitted its third amendment on March 6, 2006. This amendment made numerous clarifying, administrative and technical changes to the State plan. This amendment reinstates additional mental health benefits to the benchmark-equivalent plan for children who are diagnosed as seriously emotionally disturbed (SED); provides for private donations to be used for Federal match; replaces the Universal application with a simplified CHIP application; reduces the waiting period from three months to one month; increases the enrollment cap from 10,900 to 13,900 children; and eliminates the requirement for income documentation.

• Montana submitted its fourth amendment on July 16, 2007. This amendment expanded coverage from 150 percent to 175 percent of the Federal poverty level (FPL), add an Extended Dental Plan (EDP) in addition to the basic dental plan, and update the State Plan to reflect Montana’s current practice of contracting with a Third Party Administrator (TPA). The proposed retroactive effective date for the FPL increase is July 1, 2007, for the contract with the TPA, is October 1, 2006, and for the prospective effective date for the expansion of dental benefits, is October 1, 2007.

• Montana submitted its fifth amendment on May 6, 2009. This amendment requests approval of Federal matching funds for a $150,000 donation by the Caring Foundation of Montana to be used to provide dental services through the Montana CHIP program. This amendment has an effective date of October 1, 2009.

• Montana submitted its sixth amendment on July 31, 2009. This SPA changes Montana’s CHIP program from a separate child health program to a combination program. The Medicaid expansion program will be for children for children 6 to 18 years of age above 100 percent of the FPL up to and including 133 percent of the FPL. The SPA also increases the upper income level for the separate child health program from 175 percent of the FPL up to and including 250 percent of the FPL. The SPA makes several other changes related to program administration, eligibility determinations, adds benefits and a new source of funds. Lastly, the SPA changes the name of the program from Montana Children’s Health Insurance Plan (CHIP) to Healthy Montana Kids and Healthy Montana Kids Plus (previously Medicaid). The SPA has a retroactive effective date of October 1, 2009.

Children Covered Under Program

Montana reports that there were 17,906 ever enrolled in the State’s CHIP program in 2008.

Administration

Blue Cross Blue Shield of Montana administers Montana's Children's Health Insurance Program.

Health Care Delivery System

Montana contracts with Blue Cross Blue Shield to provide a benchmark equivalent State Employees plan for children over 133 percent of FPL and provides coverage to those at or below 133 percent of FPL through the State’s Medicaid program.

Benefit Package

• Montana offers benchmark-equivalent coverage for children above 133 percent of the FPL. The benefit package includes inpatient and outpatient hospital services; emergency room services; physician services; surgical services; lab and X-ray services; well-child and well-baby services including age appropriate immunizations; prenatal and pregnancy services; abortion as permitted by law; prescription drugs; mental health and substance abuse treatment services; hearing and vision exams (including eyeglasses); and dental benefits that includes maxillofacial surgeries and prosthetics, dental implants, surgical procedure, treatment of fractures, and orthodontia. • It offers Medicaid coverage to those at or below 133 percent of the FPL.

Cost Sharing

Cost sharing is imposed for non-Native American households above 100 percent of the FPL only, as follows: • Inpatient hospital from no out of pocket to $25 per visit • Emergency room from no out of pocket to $5 per visit • Outpatient services from no out of pocket to $5 per visit • Generic pharmaceuticals from no out of pocket to $3 per prescription • Premium pharmaceuticals from no out of pocket to $5 per prescription • Mail order generic (3 mos. Supply)--$6 per prescription • Name brand mail order (3 mos. Supply)--$10 per prescription

The third party administrator will track the copayments charged to each family. When a copayment cap of $215 is reached, a maximum copayment letter will be generated and new ID card issued stating that no copayment is required.

• Should payments exceed $215, the family would submit any receipts and would be reimbursed. • Enrollees are not disenrolled for non-payment of copayments.

State Action to Avoid Crowd Out

The application form asks families to report any health insurance coverage. A child is ineligible if the child has been covered under an individual or group health plan 3 months prior to application for CHIP, except under certain circumstances. The State monitors information collected on its eligibility and enrollment system to monitor substitution of coverage.

Outreach Activities

• Montana developed and maintains a statewide network of over 700 community partners, including health care providers, community advocacy groups, and other related agencies to increase awareness of the program, distribute applications, and offer enrollment assistance to families. In 2008, the State distributed over 13,000 brochures and applications through this network.

• In each of the past two years, the State has conducted a comprehensive back-to- school campaign in the fall. Approximately 35,000 postcards with the theme “Healthy Children Learn Better” were distributed to nearly 200 schools in 2008.

• In early 2006 the State conducted a statewide media campaign, including television, radio, and print advertising. Department staff produced all of the campaign materials in-house. A similar campaign will be conducted in support of the implementation of the Healthy Montana Kids program in the summer of 2009.

• The State staffs a telephone help-line for calls from Montanans in response to outreach campaigns, marketing, etc. The staff is knowledgeable about requirements and services available from public health programs and Medicaid- funded programs. The staff responds to public inquiries, coordinates with these programs, and makes referrals.

• The State has developed and maintained a network for referrals that includes the Women’s, Infant’s and Children’s Nutrition Program, the Title V Program, the High-Risk Pregnant Women’s Program, Federally Qualified Health Centers, Community Health Centers, Urban Indian Centers, Migrant Health Clinics, Rural Health Clinics, programs for individuals under the Disabilities Education Act, and Montana’s Children’s Mental Health Services Program among others.

Coordination between SCHIP and Medicaid

• Effective August 1, 2005, a simplified four-page application is being used for application to CHIP. When appropriate, the new application allows referral to

Medicaid, Children with Special Health Care Needs program, and the Mental Health Services Plan. The simplified application can also be downloaded from the CHIP website.

• The CHIP program screens all applicants for Medicaid eligibility. If the child is likely to be eligible for Medicaid, the application is forwarded to the County Public Assistance Office to begin the Medicaid application process. A child who is found ineligible for Medicaid is subsequently enrolled in CHIP.

• Children renewing CHIP coverage and considered to be potentially eligible for Medicaid will be provisionally re-enrolled in CHIP until it is determined that they are Medicaid eligible. This will ensure that a child does not have a lapse in coverage.

Financial Information

Total FFY 2009 SCHIP allotment -- $30,065,721 Enhanced Federal matching rate for FFY 2009 --77.6% Date Last Updated: CMS, CMSO, FCHPG, DSCHI, November 23, 2009

_____________________________________________________________________________

Table of Contents

State/Territory Name: Montana

State Plan Amendment (SPA) #: MT-13-0010

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Montana consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

ee onan ms Centers for Medicare & Medicaid Services -C M Ss

7500 Security Boulevard, Mail Stop: 82-26-12 : Baltimore, Maryland 21244-1850 CeNteR Fox MEDD & Cn EEC

Children and Adults Health Programs Group

DEC 2 4 2013 Ms. Mary E. Dalton

State Medicaid and CHIP Director

State of Montana

Department of Public Health and Human Services Post Office Box 202925

Helena, MT 59620

Dear Ms. Dalton:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) MT-13-0010 submitted on August 28, 2013 and with additional information submitted on December 5, 2013, related to Modified Adjusted Gross Income (MAGI) Eligibility has been approved with an effective date of January 1, 2014.

MAGI Eligiblity & Methods:

SPA number MT-13-0010 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children; and page CS10 allows the state to cover children who have access to public employee coverage and updates the supporting documentation. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved CS7 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan. A copy of the approved CS10 and its supporting documentation is attached; the CS10 supersedes the current information on dependents of public employees in section 4.1.7 of the current CHIP state plan, and the supporting documentation should supersede the current documentation in an Appendix to the current CHIP state plan.

Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Page 2 — Ms. Mary E. Dalton

Telephone: (410) 786-3413 Facsimile: (410) 786-5882 E-mail: Joyce. Jordan@cms.hhs.gov

Please copy Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office on all communications. Mr. Allen’s address is:

Centers for Medicare & Medicaid Services Denver Regional Office

Colorado State Bank Building

1600 Broadway, Suite# 700

Denver, Colorado 80202-4967

Congratulations on the approval. If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143.

We look forward to continuing to work with you and your staff.

Sincerely,

Eliot Fishman Director

Enclosure ec: Richard Allen, ARA, CMS Region VIII, Denver

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MT.0249.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Montana State Funds: $ Federal Funds: $ Submitted By: Jo Thompson Last Revision Date: Dec 24, 2013 Submit Date: Aug 28, 2013 Children's Health Insurance Program Eligibility: Summary Page 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. MT-13-0010 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation • CS7: 2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320 • CS10: Sec. 21 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:295 out of 2000 Implementation of ACA changes for CHIP targeted low income children. The SPAs include the changes in the FPL standard due to MAGI conversion. CS10 includes the state’s policy regarding children who have access to public employee coverage and the methodology used to calculate financial hardship. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

ccms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/3 1/2014

2102(b)(1 (Biv) of the SSA and 42 CFR 457.310. 315 and 320

a Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards established by the ’ state.

The CHIP Agency operates this covered group in accordance with the following provisions: Age

Must be under age 19. Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income

. No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here.

From Age To Age Above (% FPL) Up to & including (% FPL)

+ ilo 19 143 261 X

Age ranges may overlap. If there is an overlap. provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards.

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities?

PRA Disclosure Statement

SPA# MT-13-0010 Approval Date:, DEC 2 4 2013 Effective Date: January 1, 2014 Page | of 2

cms CHIP Eligibility

PEA ROE MUTE IAR GAAPTNC AAD IIR

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 50 hours per response, including the time to review instructions. search existing data resources. gather the data needed. and complete and review the information collection. [f 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.

/.20130709

SPA# MT-13-0010 Approval Date:, DEC 2 4 2013 Effective Date: January 1, 2014

Page 2 of 2

coms. CHIP Eligibility

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

Sec. 2110(b)(2)(B) and (b)(6) of the SSA

@ Children Who Have Access to Public Employee Coverage - Otherwise eligible targeted low-income children who have access to ’ public employee coverage on the basis of a family member's employment. [7] The CHIP Agency operates this covered group in accordance with the following provisions: Select one of the following conditions as described in Section 2110(b)(6) of the Social Security Act: C Maintenance of agency contribution as provided in 2110(b)(6\B) of the SSA. @ Hardship criteria as provided in section 2110(b)(6)(C) of the Social Security Act. Coverage under this option is extended to children whose household income is: Select one of the options for the income standard when compared to Targeted Low Income Children @ The same as the standards for Targeted Low-Income Children C Lower than the income standards for Targeted Low-Income Children

Indicate whether coverage under this option is extended to all children who have access to public employee coverage. or only certain children:

@ All children who have access to public employee coverage © Certain children who have access to public employee coverage:

[BH] Attach methodology the state has used to calculate financial hardship.

An attach at is submitted.

Ww The state provides assurance that the state will, on an annual basis, recalculate the financial status to determine if the *" hardship condition continues to be met.

w Children who are eligible for public employee health benefits coverage who are not described above are excluded from - eligibility under the plan.

WZ Children considered to have access to public employee coverage, and therefore not excluded from CHIP through this option, “" otherwise meet the definition of targeted low-income child provided at 42 CFR 457.310.

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 50 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.20130917 SPA# MT-13-0010 Approval Date:, DEC 2 4 2013 Effective Date: January 1, 2014

Page | of I

Table A State of Montana Employee Group Benefits Plan

{2012 State Contribution ("State Share") = $733/month; $8,796/year |

Annual Out of Pocket Expences for the State of Montana Employes Group Benefits Plan

= Indemnity Plan Managed Care Plans at wes ”

Plans Traditional Blue Choice [iew West Employee Only

Medical Rate (paid by “state share’) $

Deductible 5

- Coinsurance $ Total Out of Pocket (OOP) Expense > see $ tH RE

Employee & Family ;

PERE ERMA E TE LN

Medical rate minus Employee Only rate ; GE z7i2 [Deductible $ 1,800 75 850 iCoinsurance $ §,625 1S 4,500 Total Out of Pocket (OOP) Expense $ 10,137 7S 8,062 Maximum adjusted gross income at 5% of OOP $ 202,740 4$ 161,240 1S 161,240 Notes:

The managed care plans‘ deductible maximum is for in-network services, An additional deductible maximum js assessed for out of network services. The managed care plans' coinsurance maximum is for in-network services. An additional coinsurance maximum is assessed for out of network services.

SPA# MT-13-0010 Approval Date: DEC 2 4 2013 Effective Date: January 1, 2014

Table B

Montana University System Employee Group Benefits Plan

{2012 State Contribution ("State Share") = $733/month; $8,796/year

Annual Out of Pocket Expenses for the Mantana University system Employee Group Benefit Plan

Indemnity Plan

Plans

Traditional a —

Employee Only

(Medical Rate {paid by "state share”)

pDeductible

Coinsurance Total Out of Pocket (OOP) Expense

Employee & Children Medical rate minus Employee Only rate

(Deductible

fCoinsurance ‘otal Out of Pocket (OOP) Expense

Maximum adjusted gross income at 5% of OOP

Employee & Family

§Medical rate minus Employee Only rate

| $ 5,568.

{Deductible

2,250 8S

Coinsurance

Total Out of Pocket (OOP) Expense

19,068

Maximum adjusted gross income at 5% of OOP

$ $ 11,250 | $ $

381,360) $

Notes:

‘The managed care plans’ deductible maximum is for in-network services. An additional deductible maximum is assessed for out of network services. The managed care plans’ coinsurance maximum is for in-network services. An additional coinsurance maxiraum is assessed for out of network services.

http://www.mus.edu/Choices/forms.asp

SPA# MT-13-0010

DEC 2 4 2013

Approval Date: Effective Date: January 1, 2014

Hardship criteria for CHIP SPA CS10

Eligible children of State of Montana and Montana University System employees are covered in accordance with the Patient Protection & Affordable Care Act of 2010 ‘Hardship Exception to the Exclusion of Children of Employees of a Public Agency ina State’.

The methodology for determining eligibility for State of Montana and Montana University System employee's children is a two-fold test. First, the program determines if the family meets all financial and HMK coverage group (CHIP) eligibility requirements.

Second, the program compares the family’s income to a reference table for their health insurance plan out of pocket expense requirement. It is a reasonable expectation out of pocket expenses, including premiums, deductibles, coinsurance and copayments, will exceed 5% of a family’s income for families with income at or below 261% of the FPL.

The program assures an annual review of the updated state employees’ health insurance plans’ reference table. This review will evaluate the out of pocket expense requirements to assure this reasonable expectation remains valid for families at or below 261% of FPL.”

SPA# MT-13-0010 Approval Date:. DEC 2 4 2013 Effective Date: January 1, 2014

coms. CHIP Eligibility

OMB Control Number: 0938-1148 Expiration da

2102(b\(1)(B)(v) of the SSA and 42 CFR 457.315

WZ The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups, as described ‘ below, and consistent with 42 CFR 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013, MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility, whichever is later. .

If the state covers pregnant women, in determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: C The pregnant woman is counted just as herself. ; C The pregnant woman is counted just as herself, plus one. (@ The pregnant woman is counted as herself. plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size, In determining current monthly or projected annual household income. the state will use reasonable methods to: [X] Include a prorated portion of the reasonably predictable increase in future income and/or family size. [7] Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CPR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

Household income includes actually available cash support. exceeding nominal amounts. provided

by the person claiming an individual described at §435.603(1)(2)(i) as a tax. dependent. ss

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards.

An attachment is submitted.

PRA Disclosure Statement

SPA# MT-13-0010 Approval Date:, DEC 2 4 2013 Effective Date: January 1, 2014 Page | of 2

coms. CHIP Eligibility

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 50 hours per response, including the time to review instructions, search existing data resources. gather the data needed. and complete and review the information collection. [f 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.

SPA# MT-13-0010 Approval Date:, DEC 2 4 2013

Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Montana

State Plan Amendment (SPA) #: MT-13-0011

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Montana consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES ae Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

. CENTERS POR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Ms. Mary E. Dalton

State Medicaid and CHIP Director NOV 05 2013 State of Montana

Department of Public Health and Human Services

Post Office Box 202925

Helena, MT 59620

Dear Ms. Dalton:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPA) MT-13-0011, MT-13-0012 and MT-13-0014, submitted on August 28, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligiblity have been approved with an effective date of January 1, 2014.

XXI Medicaid Expansion:

SPA number MT-13-0011 converts the state’s existing income eligibility standard to a modified adjusted gross income (MAGI)-equivalent standard, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into Montana’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section 4.0 of the current CHIP state plan.

Establish 2101(f) Group:

SPA number MT-13-0012 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Montana’s approved CHIP state plan.

Non-Financial Eligibility:

SPA number MT-13-0014 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; and continuous eligibility. We are approving this SPA in the absence of state plan page CS20. The state's non-financial eligibility policy on substitution of coverage will be submitted when the state legislature has met and approved the change to the waiting period. Copies of the approved state plan pages are attached and these approved pages supersede sections of Montana’s current state plan as laid out below:

Page 2 — Ms. Mary E. Dalton

New State Plan Page

Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency

Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship

Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security

Section 4.1.9.1

Number

Section 4.1.9.2

C827: General Eligibility - Continuous Eligibility

Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

If you have questions or wish to discuss this determination further, please contact Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office. Mr. Allen’s address is:

Centers for Medicare & Medicaid Services Denver Regional Office

Colorado State Bank Building

1600 Broadway, Suite# 700

Denver, Colorado 80202-4967

Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786- 5143.

We look forward to continuing to work with you and your staff.

Sincerely,

Eliot Fishman Director

Enclosure

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MT.0248.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Montana State Funds: $ Federal Funds: $ Submitted By: Jo Thompson Last Revision Date: Oct 31, 2013 Submit Date: Aug 28, 2013 Children's Health Insurance Program Eligibility: Summary Page 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. MT-13-0011 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation • CS3: 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:112 out of 2000 Implementation of ACA changes for CHIP Medicaid Expansion children and the change in FPL due to MAGI conversion. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Page 3 — Ms. Mary E. Dalton

cc: Richard Allen, ARA, CMS Region VIII, Denver

Spi, PEL AEN NI AARC NIRS REINS

CHIP Eligibility

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

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL)

19 109 143

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 50 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.

NOV 0.5 2013

SPA # MT-13-0011 Approval Date: January 1, 2014

Page | of 1

‘CMS. CHIP Eligibility

OMB Control Number: 0938-1148

Section 2101(f) of the ACA and 42 CFR 457.310(d)

{li] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

Cc The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

[

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

. The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

e

261 % FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

C This population will be provided the same benefits as are provided to children in the state’s Medicaid program. @ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid Program,

NOVO) SPA # MT-13-0012 Approval Date: Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

concen Mien NK MRD RESPITE:

(@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. C-No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

© Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

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 50 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.

NOV 05 cut3 SPA # MT-13-0012 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

cms. CHIP Eligibility

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

42 CFR 457.320

Residency

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

A child is considered to be a resident of the state under the following conditions:

ial A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [im] A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

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

rl An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[ii] A child who is a ward of the state regardless of where the child lives, or

A child physically located in the state when there is a dispute with one or more states as to the child's actual state of (al residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [i] A non-institutionalized pregnant woman who is living in the state and:

1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or

2. Entered with a job commitment or seeking employment, whether or not currently employed.

rT An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

im An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

a A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

SPA # MT-13-0014

Approval Date: NOV 0 L 2013 Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

Sohne Pela ee MRD et aa SAIN,

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. 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 50 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.

SPA # MT-13-0014 Approval pateNOV Q § 2013 Effective Date: January 1, 2014 Page 2 of 2

CcmMs. CHIP Eligibility

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

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[mi] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity 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); or

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 satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

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 Yes verification process.

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

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:

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Yes in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program. SPA # MT-13-0014 Approval Date

Effective Date: January 1, 2014 Page | of 3

CHIP Eligibility

eases ea ares pe Ie S406

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

rh An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

{] An individual is considered to be lawfully present in the United States if he or she is:

1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

No

2. 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. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

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

(ii) 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;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) 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:

(i) Has been granted employment authorization; or (ii) 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)).

SPA # MT-13-0014 Approval Date NOV 0 3 2ntg Effective Date: January 1, 2014

Page 2 of 3

CHIP Eligibility

eatin ea mere Ri rR MeoC SINNER

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.

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 50 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.

NOV 05 2013

SPA # MT-13-0014 Approval Date : Effective Date: January 1, 2014 Page 3 of 3

CHIP Eligibility

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

42 CFR 457.340(b)

Social Security Number As acondition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

rT The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[mf] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their Ves SSN.

When requesting an SSN for non-applicant household members, the state assures that:

im At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

iw The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

NOV 05 2013

SPA # MT-13-0014 Approval Date: January 1, 2014 Page | of 2

Ss — CHIP Eligibility

VT Ren aac pay ates a

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 50 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.

NOV 0 5 2013

SPA # MT-13-0014 Approval Date: January 1, 2014

Page 2 of 2

CHIP Eligibility

psi a CTIA N ME AMEN AD I

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

|

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier.

The CHIP Agency elects to provide continuous eligibility to children under this provision. | Yes

(@ For children up to age 19

C For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[B] Attheend ofthe |12 | months continuous eligibility period.

Exceptions to the continuous eligibility period: [i] The child attains the age specified by the state Agency or age 19. [i] The child or child's representative requests voluntary disenrollment. [Hi] The child is no longer a resident of the state.

ry The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[i] The child dies.

[li] There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

Other

Describe

Child is covered under a group health plan or under health insurance coverage as defined in section 2791 of the Public Health Service Act

Child is eligible for Medicaid

PRA Disclosure Statement

NOV05 203 Effective Date: January 1, 2014

Page | of 2

SPA # MT-13-0014 Approval Date:

CHIP Eligibility

pines HoaEERC NER AATEC NIE

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 50 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.20130717

NOV 05 2013

SPA # MT-13-0014 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Montana

State Plan Amendment (SPA) #: MT-13-0012

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Montana consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES ae Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

. CENTERS POR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Ms. Mary E. Dalton

State Medicaid and CHIP Director NOV 05 2013 State of Montana

Department of Public Health and Human Services

Post Office Box 202925

Helena, MT 59620

Dear Ms. Dalton:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPA) MT-13-0011, MT-13-0012 and MT-13-0014, submitted on August 28, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligiblity have been approved with an effective date of January 1, 2014.

XXI Medicaid Expansion:

SPA number MT-13-0011 converts the state’s existing income eligibility standard to a modified adjusted gross income (MAGI)-equivalent standard, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into Montana’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section 4.0 of the current CHIP state plan.

Establish 2101(f) Group:

SPA number MT-13-0012 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Montana’s approved CHIP state plan.

Non-Financial Eligibility:

SPA number MT-13-0014 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; and continuous eligibility. We are approving this SPA in the absence of state plan page CS20. The state's non-financial eligibility policy on substitution of coverage will be submitted when the state legislature has met and approved the change to the waiting period. Copies of the approved state plan pages are attached and these approved pages supersede sections of Montana’s current state plan as laid out below:

Page 2 — Ms. Mary E. Dalton

New State Plan Page

Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency

Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship

Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security

Section 4.1.9.1

Number

Section 4.1.9.2

C827: General Eligibility - Continuous Eligibility

Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

If you have questions or wish to discuss this determination further, please contact Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office. Mr. Allen’s address is:

Centers for Medicare & Medicaid Services Denver Regional Office

Colorado State Bank Building

1600 Broadway, Suite# 700

Denver, Colorado 80202-4967

Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786- 5143.

We look forward to continuing to work with you and your staff.

Director

Enclosure

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MT.0247.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Montana State Funds: $ Federal Funds: $ Submitted By: Jo Thompson Last Revision Date: Oct 31, 2013 Submit Date: Aug 28, 2013 Children's Health Insurance Program Eligibility: Summary Page 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. MT-13-0012 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation • CS14: Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:232 out of 2000 This SPA includes the eligibility for CHIP for Medicaid children that lose coverage due to the elimination of income disregards. This coverage can continue for up to 12 months of coverage under CHIP, but no later than April 1, 2016. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/01/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Page 3 — Ms. Mary E. Dalton

cc: Richard Allen, ARA, CMS Region VIII, Denver

Spi, PEL AEN NI AARC NIRS REINS

CHIP Eligibility

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

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL)

19 109 143

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 50 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.

NOV 0.5 2013

SPA # MT-13-0011 Approval Date: January 1, 2014

Page | of 1

‘CMS. CHIP Eligibility

OMB Control Number: 0938-1148

Section 2101(f) of the ACA and 42 CFR 457.310(d)

{li] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

Cc The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

[

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

. The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

e

261 % FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

C This population will be provided the same benefits as are provided to children in the state’s Medicaid program. @ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid Program,

NOVO) SPA # MT-13-0012 Approval Date: Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

concen Mien NK MRD RESPITE:

(@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. C-No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

© Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

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 50 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.

NOV 05 cut3 SPA # MT-13-0012 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

cms. CHIP Eligibility

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

42 CFR 457.320

Residency

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

A child is considered to be a resident of the state under the following conditions:

ial A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [im] A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

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

rl An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[ii] A child who is a ward of the state regardless of where the child lives, or

A child physically located in the state when there is a dispute with one or more states as to the child's actual state of (al residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [i] A non-institutionalized pregnant woman who is living in the state and:

1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or

2. Entered with a job commitment or seeking employment, whether or not currently employed.

rT An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

im An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

a A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

SPA # MT-13-0014

Approval Date: NOV 0 L 2013 Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

Sohne Pela ee MRD et aa SAIN,

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. 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 50 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.

SPA # MT-13-0014 Approval pateNOV Q § 2013 Effective Date: January 1, 2014 Page 2 of 2

CcmMs. CHIP Eligibility

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

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[mi] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity 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); or

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 satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

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 Yes verification process.

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

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:

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Yes in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program. SPA # MT-13-0014 Approval Date

Effective Date: January 1, 2014 Page | of 3

CHIP Eligibility

eases ea ares pe Ie S406

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

rh An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

{] An individual is considered to be lawfully present in the United States if he or she is:

1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

No

2. 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. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

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

(ii) 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;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) 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:

(i) Has been granted employment authorization; or (ii) 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)).

SPA # MT-13-0014 Approval Date NOV 0 3 2ntg Effective Date: January 1, 2014

Page 2 of 3

CHIP Eligibility

eatin ea mere Ri rR MeoC SINNER

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.

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 50 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.

NOV 05 2013

SPA # MT-13-0014 Approval Date : Effective Date: January 1, 2014 Page 3 of 3

CHIP Eligibility

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

42 CFR 457.340(b)

Social Security Number As acondition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

rT The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[mf] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their Ves SSN.

When requesting an SSN for non-applicant household members, the state assures that:

im At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

iw The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

NOV 05 2013

SPA # MT-13-0014 Approval Date: January 1, 2014 Page | of 2

Ss — CHIP Eligibility

VT Ren aac pay ates a

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 50 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.

NOV 0 5 2013

SPA # MT-13-0014 Approval Date: January 1, 2014

Page 2 of 2

CHIP Eligibility

psi a CTIA N ME AMEN AD I

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

|

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier.

The CHIP Agency elects to provide continuous eligibility to children under this provision. | Yes

(@ For children up to age 19

C For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[B] Attheend ofthe |12 | months continuous eligibility period.

Exceptions to the continuous eligibility period: [i] The child attains the age specified by the state Agency or age 19. [i] The child or child's representative requests voluntary disenrollment. [Hi] The child is no longer a resident of the state.

ry The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[i] The child dies.

[li] There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

Other

Describe

Child is covered under a group health plan or under health insurance coverage as defined in section 2791 of the Public Health Service Act

Child is eligible for Medicaid

PRA Disclosure Statement

NOV05 203 Effective Date: January 1, 2014

Page | of 2

SPA # MT-13-0014 Approval Date:

CHIP Eligibility

pines HoaEERC NER AATEC NIE

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 50 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.20130717

NOV 05 2013

SPA # MT-13-0014 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: Montana

State Plan Amendment (SPA) #: MT-13-0014

(In addition to the SPA noted above, this package contains other state plan amendment approvals)

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan

The complete title XXI state plan for Montana consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES ae Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

. CENTERS POR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

Ms. Mary E. Dalton

State Medicaid and CHIP Director NOV 05 2013 State of Montana

Department of Public Health and Human Services

Post Office Box 202925

Helena, MT 59620

Dear Ms. Dalton:

I am pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPA) MT-13-0011, MT-13-0012 and MT-13-0014, submitted on August 28, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligiblity have been approved with an effective date of January 1, 2014.

XXI Medicaid Expansion:

SPA number MT-13-0011 converts the state’s existing income eligibility standard to a modified adjusted gross income (MAGI)-equivalent standard, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into Montana’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section 4.0 of the current CHIP state plan.

Establish 2101(f) Group:

SPA number MT-13-0012 describes the state’s plan to provide coverage in its separate CHIP, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Montana’s approved CHIP state plan.

Non-Financial Eligibility:

SPA number MT-13-0014 is approved to clarify the state’s non-financial eligibility policies on residency; citizenship; social security numbers; and continuous eligibility. We are approving this SPA in the absence of state plan page CS20. The state's non-financial eligibility policy on substitution of coverage will be submitted when the state legislature has met and approved the change to the waiting period. Copies of the approved state plan pages are attached and these approved pages supersede sections of Montana’s current state plan as laid out below:

Page 2 — Ms. Mary E. Dalton

New State Plan Page

Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency

Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship

Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security

Section 4.1.9.1

Number

Section 4.1.9.2

C827: General Eligibility - Continuous Eligibility

Your Title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

If you have questions or wish to discuss this determination further, please contact Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office. Mr. Allen’s address is:

Centers for Medicare & Medicaid Services Denver Regional Office

Colorado State Bank Building

1600 Broadway, Suite# 700

Denver, Colorado 80202-4967

Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs, at (410) 786- 5143.

We look forward to continuing to work with you and your staff.

Sincerely,

Eliot Fishman Director

Enclosure

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility MT.0245.R00.00 - Jan 01, 2014 Home Logout Finder Save Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Montana State Funds: $ Federal Funds: $ Submitted By: Mary Eve Last Revision Date: May 19, 2014 Submit Date: Aug 28, 2013 Children's Health Insurance Program Eligibility: Summary Page 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. MT-13-0014 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation CS17: 42 CFR 457.320 CS18: Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 45 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:896 out of 2000 Implementation of ACA changes for the new single-streamlined application. Montana will implement the rebranded Federal single streamlined paper application and a new online integrated application for multiple benefit programs. The SPA also includes the eligibility and enrollment screening procedures at initial li ti R d t i ti ill b l t d 12 Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 05/28/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

Spi, PEL AEN NI AARC NIRS REINS

CHIP Eligibility

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

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL)

19 109 143

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 50 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.

NOV 0.5 2013

SPA # MT-13-0011 Approval Date: January 1, 2014

Page | of 1

‘CMS. CHIP Eligibility

OMB Control Number: 0938-1148

Section 2101(f) of the ACA and 42 CFR 457.310(d)

{li] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

Cc The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

[

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

. The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

e

261 % FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

C This population will be provided the same benefits as are provided to children in the state’s Medicaid program. @ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid Program,

NOVO) SPA # MT-13-0012 Approval Date: Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

concen Mien NK MRD RESPITE:

(@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. C-No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

© Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

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 50 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.

NOV 05 cut3 SPA # MT-13-0012 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

cms. CHIP Eligibility

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

42 CFR 457.320

Residency

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

A child is considered to be a resident of the state under the following conditions:

ial A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and:

1. Intends to reside in the state, including without a fixed address, or

2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [im] A non-institutionalized child not described above and a child who is not a ward of the state:

1. Residing in the state, with or without a fixed address, or

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

rl An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[ii] A child who is a ward of the state regardless of where the child lives, or

A child physically located in the state when there is a dispute with one or more states as to the child's actual state of (al residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [i] A non-institutionalized pregnant woman who is living in the state and:

1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or

2. Entered with a job commitment or seeking employment, whether or not currently employed.

rT An institutionalized pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010, including foster care homes, by an agency of the state, or

im An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

a A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

SPA # MT-13-0014

Approval Date: NOV 0 L 2013 Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

Sohne Pela ee MRD et aa SAIN,

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. 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 50 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.

SPA # MT-13-0014 Approval pateNOV Q § 2013 Effective Date: January 1, 2014 Page 2 of 2

CcmMs. CHIP Eligibility

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

Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens, including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[mi] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity 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); or

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 satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

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 Yes verification process.

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

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:

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Yes in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3).

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program. SPA # MT-13-0014 Approval Date

Effective Date: January 1, 2014 Page | of 3

CHIP Eligibility

eases ea ares pe Ie S406

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- Income Pregnant Women.

rh An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

{] An individual is considered to be lawfully present in the United States if he or she is:

1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

No

2. 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. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

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

(ii) 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;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) 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:

(i) Has been granted employment authorization; or (ii) 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)).

SPA # MT-13-0014 Approval Date NOV 0 3 2ntg Effective Date: January 1, 2014

Page 2 of 3

CHIP Eligibility

eatin ea mere Ri rR MeoC SINNER

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.

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 50 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.

NOV 05 2013

SPA # MT-13-0014 Approval Date : Effective Date: January 1, 2014 Page 3 of 3

CHIP Eligibility

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

42 CFR 457.340(b)

Social Security Number As acondition of eligibility, the CHIP Agency must require individuals who have a social security number or are eligible for one as determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals, as a condition of eligibility, to furnish their social security number(s), with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

rT The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[mf] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205 and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their Ves SSN.

When requesting an SSN for non-applicant household members, the state assures that:

im At the time such SSN is requested, the state informs the non-applicant that this information is voluntary and provides information regarding how the SSN will be used; and

iw The state only uses the SSN for determination of eligibility for CHIP or other insurance affordability programs, or for a purpose directly connected with the administration of the state plan.

PRA Disclosure Statement

NOV 05 2013

SPA # MT-13-0014 Approval Date: January 1, 2014 Page | of 2

Ss — CHIP Eligibility

VT Ren aac pay ates a

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 50 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.

NOV 0 5 2013

SPA # MT-13-0014 Approval Date: January 1, 2014

Page 2 of 2

CHIP Eligibility

psi a CTIA N ME AMEN AD I

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

|

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of any changes in the family’s circumstances, during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier.

The CHIP Agency elects to provide continuous eligibility to children under this provision. | Yes

(@ For children up to age 19

C For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[B] Attheend ofthe |12 | months continuous eligibility period.

Exceptions to the continuous eligibility period: [i] The child attains the age specified by the state Agency or age 19. [i] The child or child's representative requests voluntary disenrollment. [Hi] The child is no longer a resident of the state.

ry The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[i] The child dies.

[li] There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

Other

Describe

Child is covered under a group health plan or under health insurance coverage as defined in section 2791 of the Public Health Service Act

Child is eligible for Medicaid

PRA Disclosure Statement

NOV05 203 Effective Date: January 1, 2014

Page | of 2

SPA # MT-13-0014 Approval Date:

CHIP Eligibility

pines HoaEERC NER AATEC NIE

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 50 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.20130717

NOV 05 2013

SPA # MT-13-0014 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Montana State Plan Amendments (SPA) #: MT-17-0020 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-"16 Baltinrore, MD 21244-"1850 tvts CTNITRS FOR MTOICARI & MTDICAID STRVICES CENTEN fON MEDICAID & CHIP SERVICES sEP r 4 2017 Ms. Marie Matthews State Medicaid Director Montana Department of Public Health and Human Services Post Ofhce Box 4210 Helena, MT 59604 Dear Ms. Matthews: I am pleased to inform you that your title XXI Children's Health Insurance program (CHIp) state plan amendment (SPA), MT-17-0020, submitted on June 27,2017, has been approved. The SpA has a retroactive effective date of April 1,2017. This SPA makes the Comprehensive Primary Care Plus (CPC+) Program model accessible on a voluntary basis to children in Montana's separate CHIP, Healthy Montana Kids. CpC* is a national advanced primary care medical home model, through the Center f'or Medicare and Medicaid Innovation, designed to strengthen primary care for patients with serious or chronic medical needs. CPC+ supports participating primary care practices through regionally-based multi-payer payment reform and care delivery transformation in order to improve health outcomes. The state received approval under Medicaid SPA, MT-l 7-0009, on July 31,2017, with an effèctive date of January l, 2017. Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Jordan's contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1 850 Telephone: (41 0) 786-3413 E-mail: Joyce.Jordan@cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Mr. Richard Allen, Associate Regional Administrator (ARA) in our Denver Regional Office. Mr. Allen's address is: Centers f'or Medicare & Medicaid Services 1961 Stout Street

Page2 - Ms. Marie Matthews Room 08-148 Denver, CO 80294 If you have additional questions, please contact Ms. Amy Lutzky,Directoro Division of State Coverage Programs, at (410) 786-0721. We look forward to continuing to work with you and your staff. Costello Director cc Mr. Richard Allen, ARA, CMS Region VIII, Denver / Anne Marie Costello /

1 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:___________Montana________________________________________________ (Name of State/Territory)

SPA 17-0020

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

___Mary E. Dalton___________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Mary Dalton

Position/Title: State Medicaid and CHIP Director Name: Duane Preshinger

Position/Title: Division Administrator, Health

Resources Division

*Disclosure. 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 09380707. The time required to complete this information collection is estimated to average 160 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 1005-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: o Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. o Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) o Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. o Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA: (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, which may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

3 When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42CFR, 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary-

4 approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

5 Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: o Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. o Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children's Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections) indicating State

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child

6 health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid, CHIP and Survey & Certification Mail Stop - S2-01-16

7 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements 1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)( 1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1 Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval.

1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1. and 1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval.

1.1.3.

A combination of both of the above. (Section 2101(a)(2))

Montana has had a separate child health program since 1999. Effective October 1, 2009, income eligibility guidelines increased from 175% of the federal poverty level (FPL) to 250% of the FPL. The name of the program will changed from Montana Children’s Health Insurance Plan (CHIP) to the Healthy Montana Kids (HMK) coverage group of the Healthy Montana Kids Plan. Effective January 1, 2014, the income eligibility guidelines increasesd to 261% of the FPL.

Effective October 1, 2009, DPHHS implemented a CHIP-funded Medicaid Expansion Program for children 6-18 years of age whose family’s income is at or below 133% of the FPL. Children enrolled in the CHIP-funded Medicaid Expansion Program must meet all Medicaid eligibility requirements. They will receive the Medicaid package of benefits and access to the Medicaid network of providers. Provider reimbursement will be at the Medicaid provider rates. The CHIP-funded Medicaid Expansion Program will be part of the Healthy Montana Kids Plus coverage group of the Healthy Montana Kids Plan.

8 Effective January 1, 2014, the CHIP-funded Medicaid Expansion income eligibility guidelines for children 6-18 years of age increased to include family incomes at or below 143% of the FPL.

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5)) 1.2

Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) 1.3

Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4 Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Effective Date: January 1, 1998

Implementation Date: January 1, 1998

SPA # 1. Purpose: Establishinged an enrollment cap of 10,100 children effective 1/1/2001; adoption of a universal application form; modification of definition of countable income; elimination of the annual enrollment fee; exclusion of coverage for contraceptives; addition of a $350 dental benefit and an eyeglass benefit; an increase in the annual maximum copayment from $200 to $215; and elimination of cost-sharing for Native American children enrolled in CHIP. Effective Date: June 1, 2000

9 Implementation Date: June 1, 2000

SPA #2. Purpose: Updated and amended to indicate Montana’s compliance with final CHIP regulations. Amendment reduced mental health benefits although the following benefits remained— inpatient and outpatient mental health services and prescription drugs. Effective Date: July 1, 2002

Implementation Date: July 1, 2002

SPA #3. Purpose: SPA #3 made clarifying, administrative and technical changes to the State pPlan. It reinstated additional mental health benefits to the benchmark-equivalent plan for children diagnosed as seriously emotionally disturbed (SED); provided for private donations to be used for Federal match; replaced the Universal application with a simplified CHIP application; reduced the waiting period from three months to one month; increased the enrollment cap from 10,900 to 13,900 children; and eliminated the requirement for income documentation. Effective Date: October 1, 2005

Implementation Date: October 1, 2005

SPA #4. Purpose: SPA #4 expanded coverage from 150 percent to 175 percent of the Federal Poverty Level (FPL); added an Extended Dental Plan (EDP) in addition to the basic dental plan, and updated the State Plan to reflect Montana’s current practice of contracting with a Third Party Administrator (TPA). Effective Date: October 1, 2006

Implementation Date: TPA contract, October 1, 2006; FPL increase, July 1, 2007; Extended Dental Plan, October 1, 2007

SPA #5. Purpose: SPA #5 requested approval of Federal matching funds for a $150,000 donation by the Caring Foundation of Montana to be used to provide dental services through the Montana CHIP program. This amendment has an effective date of October 1, 2009. Effective Date: October 1, 2009

Implementation Date: October 1, 2009

SPA #6. Purpose: SPA #6 changed Montana’s CHIP program from a separate child health program to a combination program. The Medicaid expansion program includes children 6 to 18 years

10 of age above 100 percent of FPL up to and including 133 percent of FPL. SPA #6 also increased the upper income level for the separate child health program from 175 percent of FPL up to and including 250 percent of FPL. SPA #6 made other changes related to program administration and eligibility determinations, and added benefits and a new source of funds. Lastly, SPA #6 changed the name of the program from Montana Children’s Health Insurance Plan (CHIP) to Healthy Montana Kids and Healthy Montana Kids Plus (previously children’s Medicaid). Effective Date: October 1, 2009

Implementation Date: October 1, 2009

SPA #7. Purpose: SPA #7 allowed for coverage of eligible children of State employees and Montana University System employees with family incomes within the HMK income guidelines. The coverage was provided in accordance with the “Hardship Exception to the Exclusion of Children of Employees of a Public Agency of a State” of the Patient Protection and Affordable Care Act of 2010. Effective Date: December 1, 2010

Implementation Date: December 1, 2010

SPA #8. Purpose: SPA #8 removed some annual limits for inpatient and outpatient medical, mental health, and substance use disorder benefits. It also expanded coverage to children lawfully residing in the U.S., provided Prospective Payment for FQHCs and RHCs, and created an exception to the three -month insurance delay for children of military personnel losing eligibility for Trico and for children from families with annual out of pocket health care costs exceeding 5 percent of the family’s income. It added emergency ambulance services as a covered benefit, removed cochlear implants as a covered benefit, increased the maximum basic dental benefit to $1,200 per member per benefit year, made programmatic updates to tribal consultation, the schedule of mailings, and the appeals process, and provided for Presumptive Eligibility. Effective Date: October 1, 2009

Implementation Dates: July 1, 2010 – Removed some annual limits for inpatient and outpatient medical, mental health, and substance use disorder benefits;

August 1, 2010 – Expanded Coverage to Children Lawfully Residing in the United

States;

October, 1, 2009 – Provided Prospective Payment System for FQHCs and RHCs; October 1, 2010 -- Applied as an exception to the three month insurance delay period children of military personnel who lose eligibility for Trico insurance (retroactive to

11 October 1, 2009); applied as an exception to the three month insurance delay period children from families with annual aggregate amount of premiums and cost-sharing exceeding 5 percent of family’s income; added emergency ambulance services as a covered benefit and removed cochlear implants and associated components as covered benefits; increased the maximum basic dental benefit to $1,200 per member per benefit year; made programmatic updates related to tribal consultation, the schedule of mailings, and the appeals process; and

January 1, 2011 -- provided for Presumptive Eligibility.

SPA #_9. Purpose:

The purpose of SPA #9 is was to apply the new enrollment standard that children are enrolled the first of the month in which they are eligible if an insurance delay does not apply; to implement administrative redeterminations and Ex Parte redeterminations; to clarify the program will not pay providers outside the United States; to clarify DPHHS will send disenrollment notification to enrollees ten days prior to the termination of program benefits; to clarify enrollees are entitled to receive program benefits during the Fair Hearing process pending outcome of a review; and to add the following as covered benefits: chiropractic services; cochlear implants; durable medical equipment; home health services; hospice services; nutrition services; transplants (organ and tissue); and medical transportation/per diem.

Effective Date: October 1, 2012

Implementation Dates:

November 1, 2011 – Enrollment the first of the month children are eligible if an

insurance delay does not apply;

April 1, 2012 – Administrative Redeterminations and Ex Parte Redeterminations;

October 1, 2012 – Clarification of no payment to providers outside the U.S.; and

clarification disenrollment notification will be provided ten days prior to termination of

program benefits;

October 1, 2012 – Addition of the following benefits: cochlear implants; home health

services; hospice services; nutrition services; transplants (organ and tissue); and medical

transportation/per diem;

January 1, 2013 – Addition of the following benefits: chiropractic services and durable

medical equipment.

SPA #10. Purpose: SPA #10 assuresd that Montana will apply methodologies based on a modified adjusted gross income (MAGI) standard for all separate CHIP covered groups; using the approved MAGI conversion plan income thresholds from above 143% through 261% of FPL. SPA #10 Effective Date: January 1, 2014

SPA #10 Implementation Date: January 1, 2014

12 SPA #11 Purpose: SPA #11 convertsed the state’s existing income eligibility standard to a MAGI standard, by age group, for children covered in its Title XXI-funded Medicaid program. For children ages 6-19 years, the CHIP-funded Medicaid expansion group covers children from above 109% through 143% of FPL SPA #11 Effective Date: January 1, 2014

SPA #11 Implementation Date: January 1, 2014

SPA #12 Purpose: SPA #12 providesd coverage in Montana’s separate CHIP program to children who are ineligible for Medicaid due to elimination of Income Disregards. SPA #12 Effective Date: January 1, 2014

SPA #12 Implementation Date: January 1, 2014

SPA #13 Purpose: SPA #13 incorporatesd the MAGI-based eligibility process requirements, including the single streamlined application, into Montana’s CHIP State Plan in accordance with the Affordable Care Act. The approval of this SPA includes full approval of Montana’s single streamlined paper and online applications. SPA #13 Effective Date: October 1, 2013

SPA #13 Implementation Date: October 1, 2013

SPA #14 Purpose: SPA #14 clarifiesd Montana’s non-financial eligibility policies on residency; citizenship; social security numbers; and continuous eligibility.

SPA #14 Effective Date: January 1, 2014

SPA #14 Implementation Date: January 1, 2014

SPA #15. Purpose: The purpose of SPA#15 is was to modify the pharmacy benefits for Members. The Department will administer the pharmacy benefit and will utilize the Medicaid formulary and rules. Effective Date: October 1, 2013

Implementation Date: October 1, 2013

SPA #16. Purpose:

The purpose of SPA #16 is was to remove the Extended Dental Benefit, increase the basic

13 dental benefit, and change the dental benefit year; add coverage of some over-the – counter medications; add coverage of enteral formula for the medically necessary conditions in addition to inborn errors of metabolism; add a telemedicine benefit; clarify that mammograms, services provided by physician assistants, supplies, surgical supplies, maternity services, hospital services related to pregnancy, I.V. injections and set up for I.V. solutions, respiratory therapy, cleft/cranial, metabolic, and cystic fibrosis clinics, dental implants, limited physician consultation, limited therapeutic family care, and limited day treatment are covered; and that sterilizations are not covered.

Effective Date: July 1, 2014

Implementation Date: July 1, 2014

SPA #15-0017. Purpose: The purpose of SPA #15-0017 is was to remove the 3 month waiting period for enrollment of insured children, comply with federal provider credentialing rules, allow per diem and transportation for one adult companion for a child receiving medically necessary out-of-town or out-of-state medical services, clarify that organ and tissue procurement and transplant related medical services for living donors are part of the transplant benefit, clarify that weight gain drugs are covered when medically necessary, allow over-the-counter steroid nasal sprays and benzoyl peroxide, and modify the reference to the Drug Use Education (DUE) Concurrent and Retrospective Evaluation (CARE) Board to reflect the current title of Drug Utilization Review (DUR) Board. Effective Date: July 1, 2015

Implementation Date: July 1, 2015

Reimbursement for services provided by naturopathic physicians will be eliminated effective October 1, 2015.

SPA #15-0018. Purpose: The purpose of SPA #15-0018 is was to add folic acid as a covered nonprescription product, and to amend the reference to CHIP provider screening and enrollment requirements to CFR 457.990(a).

Implementation Date: January 1, 2016

SPA #16-0019. Purpose: The purpose of SPA #16-0019 is was to give contracted tribal entities the authority to determine CHIP eligibility under the direction of the Montana Department of Public Health and Human Services.

Implementation Date: January 1, 2016

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SPA #17-0020. Purpose: The purpose of SPA #17-0020 is to allow contracted primary care practices to provide their care coordination services to Healthy Montana Kids members.

Implementation Date: April 1, 2017

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

TN No: 14-0046 Approval Date: 1/15/15 Effective Date : 12/1/14

Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description. • Population • Number of uninsured • Race demographics • Age Demographics • Info per region/Geographic information

2.1. Describe the extent to which, and manner in which, children in the State (including targeted low- income children and other groups of children specified) identified by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102(a)(1)); (42 CFR 457.80(a))

The 2003 Montana Household Survey was conducted as a stratified random digit dial telephone survey. The data were collected by the Survey Research Center at the University of Montana – Missoula, Bureau of Business and Economic Research. The survey collected information on the health insurance status of each person in the household and some demographic information about the primary wage earner in the household. Seventeen percent (17%) or approximately 41,723 children between ages 0 through 18 were uninsured at all income levels and approximately

15 35,900 uninsured children lived in households at or below 200% FPL. Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)) ; (ARRA #2,

CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act)

requires a State in which one or more Indian Health Programs or Urban Indian Organizations

furnish health care services to establish a process for the State Medicaid agency to seek advice

on a regular, ongoing basis from designees of Indian health programs, whether operated by the

Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination

and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian

Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to

apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is

required concerning Medicaid and CHIP matters having a direct impact on Indian health

programs and Urban Indian organizations.

Describe the process the State uses to seek advice on a regular, ongoing basis from federally- recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice.

Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4.

Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed health care plans (including fully and partially capitated plans); contracts with indemnity health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems.

3.1. Delivery Standards Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and

16 the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

Montana’s population is approximately 957,861. Of this number, excluding Medicare Advantage Plan enrollees, there are approximately 43,693 HMO certificate holders receiving health care services through a Health Maintenance Organization (HMO). A low penetration rate for managed care required that Montana rely primarily on indemnity insurance plans for coverage. DPHHS offered to contract with indemnity plans willing to meet the contracting criteria. In this way, DPHHS hoped to offer clients a choice in the more populated areas of the state. Until September 2006, DPHHS contracted with one indemnity plan, Blue Cross Blue Shield of Montana, and no HMOs.

In an effort to decrease administrative expenses, DPHHS issued a Request for Proposal (RFP) for Third Party Administrative (TPA) Services in early 2006. DPHHS contracted with Blue Cross Blue Shield of Montana for TPA services effective October 1, 2006.

The third party administrative (TPA) contract addresses the following areas: cost sharing, enrollment, marketing, benefits, provider network, utilization management, quality of care, access to care, member rights, civil rights, and grievance procedures. Contract standards are based on a review of standards from the following sources: National Association of Insurance Commissioners (NAIC) Model Acts, National Committee for Quality Assurance (NCQA) Accreditation Standards, and existing Medicaid contracts.

Montana may vary significantly from provider standards established in other states. Montana is a frontier state characterized in the east by sparsely populated plains and in the west by small clusters of populations separated by mountain ranges. Given the diversity in geography and population density, Montana is unable to use a single distance and/or travel time to gauge adequacy of a provider network. Instead, availability of primary care practitioners and specialists in the normal service delivery area is decided for each town or locale. This model which is used by HMK has proven successful in our Medicaid PASSPORT program (our primary care case management model) that has been in operation since 1993. We find in a frontier state such as Montana this case-by-case approach is more meaningful to clients who are accustomed to, and often choose to, live extended distances from services.

Essential Community Providers The TPA contractor is required to offer a provider network contract to Title X Family Planning providers, Indian Health Service providers, Tribal Health providers, Urban Indian Centers, Migrant Health Centers and county public health departments. The contract must offer terms and conditions at least as favorable as those offered to other entities providing the same or similar services. This provision is only in effect, however, if the afore-named entities substantially meet the same access and credentialing criteria as other contract providers and only for geographic areas jointly served by the entities and the plan.

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Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act, including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS’ Regional Office for review and approval. (Section 2103(f)(3))

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42CFR, 457.490(b))

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102)(a)(4) (42CFR 457.490(b))

The TPA contractor performs primary utilization management functions. Contract standards require adequate staff and procedures to ensure services provided to enrollees are medically necessary and appropriate. At a minimum, the TPA Contractor must address the use of referrals, prior authorizations, and client educational services.

The TPA Contractor must comply with requirements of applicable Montana law and rules governing health care quality control.

The TPA contractor’s physician incentive plans shall include no specific payment directly or indirectly to a physician or physician group as an inducement to reduce or limit medically necessary benefits furnished to a child.

The TPA Contractor is required to have an external quality review process.

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DPHHS must approve the complaint resolution process for addressing enrollees’ complaints and appeals. Upon enrollment, and at least annually thereafter, the TPA Contractor must inform enrollees of the complaint resolution process. The TPA Contractor must submit quarterly reports to DPHHS summarizing any complaint handled during the previous quarter. DPHHS must review all contractor complaint decisions.

The TPA Contractor must submit Healthcare Management Reports on a quarterly basis and the following HEDIS measures on an annual basis: access to primary care, childhood immunization status, adolescent immunization status, appropriate use of asthma medications, well-child visits (in the first 15 months and annually from age three to six) and adolescent well-care visits.

The TPA Contractor encourages the use of a primary care provider (PCP) to serve as a child’s medical home. The PCP should perform all routine non-emergency care for the child and make necessary arrangements for a child who needs referral to a specialist or hospital. A specialist could serve as a child’s primary care provider. The state Medicaid program has extensive experience in using a PCP system and offers technical assistance.

The TPA Contractor includes in its educational materials for enrollees and providers information about additional services available to children with special health care needs. Examples of these services are the Children’s Mental Health Services Plan, Children’s Special Health Services (Title V), public health case management services for pregnant women and children.

Section 4. Eligibility Standards and Methodology

Guidance: The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. Included on the template is a list of potential eligibility standards. Please check off the standards that will be used by the state and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, describe how they will be applied and under what circumstances they will be applied.

States electing to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan or combination plan should check the appropriate box and provide the ages and income level for each eligibility group.

If the State is electing to take up the option to expand Medicaid eligibility as allowed under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as well as update the budget to reflect the additional costs if the state will claim title XXI match for these children until and if the time comes that the children are eligible for

19 Medicaid.

4.0.

Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group:

4.1. Separate Program Check all standards that will apply to the State plan. (42CFR 457.305(a) and 457.320(a)) 4.1.0 Describe how the State meets the citizenship verification requirements. Include

whether or not State has opted to use SSA verification option.

4.1.1 Geographic area served by the Plan if less than Statewide:

4.1.2 Ages of each eligibility group, including unborn children and pregnant

women (if applicable) and the income standard for that group:

The HMK coverage group (separate CHIP program) is available to children ages zero through eighteen. Coverage for a child will continue through the end of the month of the child’s 19th birthday.

4.1.2.1-PC Age: _______________ through birth (SHO #02-004,

issued November 12, 2002)

4.1.3 Income of each separate eligibility group (if applicable):

Income: Children from families whose adjusted gross income is at or below 261% of the federal poverty level are eligible for the HMK coverage group (CHIP) effective October 1, 2009. Earned (wages, tips, salaries, etc.) and unearned (child support, unemployment, etc.) income is counted when determining adjusted gross income. Any income excluded by other federal statute is not counted.

The current HMK Plus (Medicaid) eligibility guidelines are up to 143% FPL for children less than 6 years of age and above 109% FPL for children between 6 and 19 years of age.

The CHIP-funded Medicaid expansion program will provides HMK Plus coverage group benefits for children 6 -18 years of age with family incomes above 109% and up to and including 143% FPL. All eligible children in a family regardless of the age of the children will have HMK Plus coverage if the family income is 143% FPL or less. This standard eligibility guideline makes it easier for families because the children are enrolled in the same coverage group, have the same benefits and provider network.

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Beginning January 1, 2014 all eligible children with family incomes at or below 143% FPL will be enrolled in HMK Plus and those with family incomes 143% and up to and including 261% will be in the HMK coverage group.

For purposes of determining financial eligibility for the HMK coverage group, a family unit consists of:

1. The child for whom the family is applying 2. The natural or adoptive parents of the child 3. The spouse of the child’s natural or adoptive parent 4. The child’s siblings (natural, adoptive, half, or step) from ages zero through eighteen, with the following exception: If a sibling between ages 19 through 22 is attending school, he or she may be counted in the family unit. 5. The child’s (i.e., emancipated minor) spouse

An unmarried emancipated minor who applies for the program is considered his or her own family.

Effective October 1, 2009, DPHHS requires income verification when a family applies for the HMK Plan. Families are required to provide documentation for all countable income.

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through

________% of the FPL (SHO #02-004, issued November 12, 2002)

4.1.4 Resources of each separate eligibility group (including any standards

relating to spend downs and disposition of resources):

4.1.5 Residency (so long as residency requirement is not based on length of

time in state):

U.S. Citizenship and Montana residency are required. A Montana resident is anyone who declares him-or-herself to live in the state, including migrant and other seasonal workers. The parent is required to certify on the application that the child is a U.S. citizen, or Qualified Alien and a Montana resident. Montana follows federal guidelines in determining whether a child is a U.S. citizen, or Qualified Alien.

DPHHS requires citizenship verification for the HMK Plus coverage group including the CHIP-funded Medicaid expansion program. DPHHS is

21 implementing citizenship verification for the HMK coverage group effective October 2009. DPHHS allows enrollment in the HMK Plan (HMK and HMK Plus) with a reasonable opportunity to verify citizenship or residency status. If the HMK application states the child was born in Montana, DPHHS will verify citizenship through Montana vital records. As of January 1, 2010, HMK is successfully using the SVES interface to verify citizenship and identity on 97 percent of all new applicants.

4.1.6 Disability Status (so long as any standard relating to disability status

does not restrict eligibility):

No child is denied eligibility based on disability status. If the child receives SSI and is eligible for Medicaid, the child is denied coverage because of Medicaid eligibility not for disability status.

4.1.7 Access to or coverage under other health coverage:

A child is found ineligible when: 1) the child is covered under a group health

plan or under health insurance coverage as defined in section 2791 of the Public Health Service Act; or 2) the child is eligible for Medicaid.

Eligible children of State of Montana and Montana University System employees are covered in accordance with the Patient Protection & Affordable Care Act of 2010 “Hardship Exception to the Exclusion of Children of Employees of a Public Agency in a State”.

The methodology for determining eligibility for State of Montana and Montana University System employee’s children is a two-fold test. First, the program determines if the family meets all financial and HMK coverage group (CHIP) eligibility requirements.

Second, the program compares the family’s income to a reference table for their health insurance plan out of pocket expense requirement. It is a reasonable expectation out of pocket expenses, including premiums, deductibles, coinsurance and copayments, will exceed 5% of a family’s income for families with income at or below 261% of the FPL.

The program assures an annual review of the updated state employees’ health insurance plans’ reference table. This review will evaluate the out of pocket expense requirements to assure this reasonable expectation remains valid for families at or below 261% of FPL.

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4.1.8 Duration of eligibility, not to exceed 12 months:

Eligibility is re-determined every 12 months. Once a child is determined eligible, he or she remains eligible unless the child moves from the state, moves in-state and DPHHS is unable to locate the family, family initiates an application and is found eligible for the HMK Plus/children’s Medicaid coverage group, is found to have other creditable health insurance coverage, turns 19, dies, becomes an inmate of a public institution, or reapplies and the child is determined ineligible. Should a child become ineligible, DPHHS will send written notification of disenrollment ten days prior to the termination of program benefits.

Eligible children on the initial application will have the same 12 month continuous eligibility period. Children who enroll at a later date may receive less than 12 months of continuous eligibility during their first year of enrollment. DPHHS chose to add the new child to the existing eligibility period in order to synchronize the reapplication/renewal period for all children in the family. Without this policy, a family would be required to re-apply for coverage for various children in the family at multiple times throughout the year.

4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 457.310 and 457.320 that are not addressed above. For instance:

Administrative Redetermination. DPHHS will send a pre-populated renewal form with all available eligibility information to the family 11 months after a child(ren) is determined eligible for HMK in order to allow time for a new eligibility span to be established. The child(ren)’s coverage will continue unless the family responds with more current information that affects eligibility. If there are changes to household composition, annual income, or health insurance coverage, the renewal form must be completed, signed, dated and returned by a specified date for purposes of eligibility redetermination.

Ex Parte Redetermination. DPHHS will determine ongoing eligibility through ex parte redeterminations in which all information available to the agency is reviewed and the parent/representative is only contacted for information DPHHS is unable to obtain or verify.

Guidance: States may only require the SSN of the child who is applying for coverage. If SSNs are required and the State covers unborn children, indicate that the unborn children are exempt from providing a SSN. Other standards

23 include, but are not limited to presumptive eligibility and deemed newborns.

4.1.9.1 States should specify whether Social Security Numbers (SSN) are required.

A Social Security Number (SSN) is required for a child who applies for benefits. Services are not denied or delayed to an otherwise eligible child pending issuance of the child’s SSN. The program follows all HIPAA related confidentiality standards and restricts the use or disclosure of information concerning applicants and enrollees to purposes directly connected with administration of the plan.

Guidance: States should describe their continuous eligibility process and populations that can be continuously eligible.

4.1.9.2 Continuous eligibility

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

Guidance: States have the option to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1)“lawfully residing” children described at section 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In other words, a State that chooses to cover pregnant women under this option must otherwise cover pregnant women under their State plan as described in 4.1.11. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

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4.1- LR

Lawfully Residing Option (Sections 2107(e)(1)(J) and 1993(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101- 649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or

25 (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Elected for pregnant women. Elected for children under age __19___.

4.1.1-LR The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, it has verified, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

CHIP and Medicaid work collaboratively and closely on policies relating to lawfully residing children. Both programs define “lawfully residing” in the same manner. The State is not choosing the enhanced match, since Medicaid estimates no more than six children in the state will meet the LAPR criteria and the administrative expenses added for separately tracking those children exceed the costs of receiving an enhanced match. Currently only one child meets thisese criteria in Medicaid, and the Medicaid policy has been in effect since January, 2010.

4.1-DS Supplemental Dental (Section 2103(c)(5) - A child who is eligible to enroll in dental-only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low- income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

4.2. Assurances The State assures by checking the box below that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1. These standards do not discriminate on the basis of diagnosis.

4.2.2. Within a defined group of covered targeted low-income children, these

26

standards do not cover children of higher income families without covering

children with a lower family income. This applies to pregnant women included

in the State plan as well as targeted low-income children.

4.2.3. These standards do not deny eligibility based on a child having a pre-existing

medical condition. This applies to pregnant women as well as targeted low-

income children.

4.2-DS Supplemental Dental Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1-DS These standards do not discriminate on the basis of diagnosis.

4.2.2-DS Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income.

4.2.3-DS These standards do not deny eligibility based on a child having a pre-

existing medical condition.

4.3 Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section 2102)(b)(2)) (42CFR, 457.350)

Guidance: The box below should be checked as related to children and pregnant women. Please note: A State providing dental-only supplemental coverage may not have a waiting list or limit eligibility in any way.

DPHHS will implement a combined application for the HMK Plan. This application will be distributed statewide and is accessible on the Internet. Both the HMK Plan office and county Offices of Public Assistance will continue accepting and processing previous versions of the programs’ applications.

DPHHS will accept and determine eligibility for all applications for children’s health coverage provided by the Healthy Montana Kids Plan. Applications may be submitted directly to the Healthy Montana Kids Plan office or any county Office of Public Assistance (OPA). DPHHS staff in each location will screen for potential eligibility for the HMK Plan. Staff at the OPA and HMK Plan offices will coordinate eligibility determination activities and enroll eligible children in the appropriate HMK Plan coverage group, HMK or HMK Plus.

27 DPHHS is developing and implementing a computerized eligibility determination system for DPHHS health and social service programs e.g. Medicaid, Supplemental Nutrition Assistance Program (SNAP), etc. The HMK Plan will be a module in this eligibility determination system. The system will improve the accuracy and coordination between the HMK Plan coverage groups and with other DPHHS programs.

DPHHS performs the following functions as part of the eligibility determination process:

• Log and scan applications and pertinent documents into the electronic file system; • Process applications; • Determine eligibility; • Refer applicants to Children’s Special Health Services, Children’s Mental Health Services, Montana Community Health Centers, or private health plans, as appropriate (Referral to other programs will not stop the HMK Plan eligibility determination process.); • Staff a toll-free information number families may call to receive information about children’s health coverage and eligibility; • Send annual renewal notices to enrollees; • Provide support for application and outreach sites; • Provide a complaint process for applicants; • Facilitate a smooth transition between different DPHHS providers and private insurances; • Provide eligibility data needed for annual reports; • Conduct Quality Assurance Audits; and • Provide a listing of HMK Enrollment Partners and CHIPRA Coalition Partners.

Eligibility Determination:

Eligibility for HMK will be determined by DPHHS or its contracted tribal designee. Any tribal eligibility determinations will be done according to DPHHS standards and under the supervision of DPHHS.

Children ages zero 0 to 19 in families whose countable income is at or below 261% of the federal poverty level are eligible if all other eligibility criteria are met.

HMK eligibility is determined within 45 calendar days after receipt of a completed application. By the forty-fifth calendar day, a letter is sent to the family notifying them of the children’s eligibility status or requesting more information to complete the application process.

The 45 -day eligibility determination time period begins the day the application is received and date stamped.

Enrollment in the Health Plan: Except for a newborn child, an eligible child’s HMK enrollment begins the later of:

28 1. The first day of the month an application is received; 2. The first day of the month the family reports a new child joined the family; or 3. The first day of the month after an insurance delay period has ended. A newborn from a family with siblings enrolled in HMK will be enrolled effective the date of birth when the family reports the birth during the birth month or within ten days of birth. If the family reports the birth of the newborn more than ten days after birth, or not within the month of birth, the newborn will be enrolled on the first day of the month notification is received. Per Section 2112(e) of the Social Security Act, children born to HMK enrollees are deemed eligible as of their date of birth for a period of 31 days, when eligibility is evaluated. Based on eligibility, they are either referred to HMK Plus (children’s Medicaid), or they remain enrolled in HMK.

Redetermination of Eligibility: Children are continuously eligible unless the child’s status changes (see Section 4.1.8).

The following is a schedule of the administrative renewal mailing sent to families:

• A renewal form pre-populated with all available eligibility information is mailed to the family one month before HMK coverage is scheduled to end. The child’s coverage will continue unless the family responds with more current information that affects eligibility. • HMK may determine ongoing eligibility through ex parte redeterminations in which all information available to the agency is reviewed and the parent/representative is only contacted for information HMK is unable to obtain or verify.

4.3.1. Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(4)) (42CFR, 457.305(b))

Check here if this section does not apply to your State.

Montana currently has no waiting list, but our enrollment is limited by federal and state funds that have been appropriated to the program. If Montana should need to establish a waiting list in the future, the following procedure will be implemented. When the maximum number of children is enrolled, the enrollment is capped and a waiting list is established. The waiting list is for children determined eligible but for whom space is not available. Children are placed on the waiting list in the order in which they are determined eligible. Applicants are notified in writing if their children are eligible and placed on the waiting list. Applicants are also informed that they can contact DPHHS to inquire about their child’s position on the waiting list. Spaces become available at the end of each month when enrollment ends for currently enrolled children who:

1. turned age 19;

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2. became eligible for HMK Plus coverage;

3. obtained coverage under another insurance;

4. moved out of state;

5. failed to reapply;

6. reapplied but were determined ineligible;

7. moved within the state and DPHHS is unable to locate the family; or

8. died.

When space becomes available, children are removed from the waiting list and enrolled until all spaces are filled. Applicants are notified in writing when their children are taken off the waiting list and are enrolled. Children on the waiting list are enrolled based on when they are determined eligible.

If space is available for at least one child, families with more than one eligible child on the waiting list will have all children enrolled at the same time. The children will all have the same enrollment date.

A child determined eligible who has a sibling already enrolled will not be placed on the waiting list. The newly eligible child is enrolled the first of the month after the Healthy Montana Kids Plan is notified. The renewal date for the newly eligible child will be the same as currently enrolled sibling.

Note: There is no waiting list for the HMK Plus coverage group, including the CHIP Medicaid expansion program.

Guidance: Note that for purposes of presumptive eligibility, States do not need to verify the

citizenship status of the child. States electing this option should indicate so in the

State plan. (42 CFR 457.355)

4.3.2. Check if the State elects to provide presumptive eligibility for children that

meets the requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR

457.355)

DPHHS will provide temporary HMK coverage group benefits to uninsured children under age 19 during a period of presumptive eligibility following a determination by a qualified presumptive eligibility provider. The effective date for implementing presumptive eligibility is January 1, 2011.

Temporary HMK coverage group benefits will begin on the date a qualified entity trained and certified by HMK makes a determination of presumptive eligibility based on information provided by the child’s parent or guardian on a presumptive eligibility application. Presumptive eligibility will end on the earlier of the date HMK makes a