DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 Region VIII February 10, 2011 Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620 Re: SPA MT-08-016 Dear Ms Dalton: We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 08-016. This SPA concerns targeted case management for chronically mentally ill adults. Please be informed that this State Plan Amendment is approved effective July 1, 2008. We are enclosing the CMS-179 and the amended plan page(s). If you have any questions regarding this SPA please contact Diane Dunstan-Murphy at 303-844­ 7040. Sincerely, /s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children’s Health Operations Cc: Duane Preshinger Jo Thompson

DEPARTMENT OF HEALTH ANDHUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO W38 0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1 TRANSMITTAL NUMBER 2 STATE STATE PLAN MATERIAL 08 016 Montana FOR HEALTH CARE FINANCING ADMINISTRATION 3 PROGRAM IDENTIFICATION Title XIX ofthe Social Security Act Medicaid TO REGIONAL ADMINISTRATOR 4 PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 7f1 08 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5 TYPE OF PLAN MATERIAL Check One NEW STATE PLAN I AMENDMENT TO 13E CONSIDERED AS NEW PLAN XEI AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Rearale tra each amendment 6 FEDERAL STATUTE REGULATION CITATION 7 FEDERAL BUDGET IMPACT 42 CRF Paris 431 440 and 441 a IFFY NA CMS 2237 IFC b IFFY SNA 8 PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9 PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT IfApplicable Supplement I B to Attachment 3 1A B Supplement I B to Attachment 31A B Service 19 Service 19 Case Management Chronically Mentally III Adults Case Management Chronically Mentally III Adults 10 SUBJECT OF AMENDMENT TCM Program compliance with 2237 IFC 11 GOVERNOR S REVIEW Check Otte GOVERNOR S OFFICE REPORTED NO COMMENT XM OTHER AS SPECIFIED COMMENTS OF GOVERNOR SOFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS 01 SUBMITFAL 12 SIGNATURE OF STATE AGENCY OFFICIAL 16 RETURN TO Montana Dept of Public Health and Human Services 13 TYPED NA E Dalton Mary E Dalton T State Medicaid Director 14 TITLE State Medicaid Director Attn Jo Thompson PO Box 4210 15 DATE SUBMfT TED Helena MT 59604 FOR REGIONAL OFFICE USE ONLY 17 DATE REJEIVED j ai e DATEAPPROVED g 0411 0 15 41 18 49 11611 0 PLAN APPROVED ONE COPY ATTACHED 19 EFFECTIVE DATE OF APPROVED MATERIAL 20 CIAL 21 TYPEDNM A4 22 T1TLEt 23 REMARKS FORM HCFA 179 07 92

SUPPLEMENT 1B to Attachment 3 1A Service 19 Case Management Services Chronically Mentally III Adults Page 1 A Target Group Adults with Severe Disabling Mental Illness SDMIJ Targeted Case Management TCM services are furnished to assist Medicaid eligible adults with severe disabling mental illness SDMI in gaining access to needed medical social educational and other services Services are provided by a licensed mental health center with a license endorsement permitting the mental health center to provide case management services An adult with severe disabling mental illness is defined as A person who is 18 or more years of age that the person meets the requirements of 4 a b c or d The person must also meet the requirements of 4 e The person a has been involuntarily hospitalized for at least 30 consecutive days because of a mental disorder at Montana State Hospital Warm Springs campus at least once b has recurrent thoughts of death recurrent suicidal ideation or a suicide attempt or a specific plan for committing suicide c has a DSMIVTR diagnosis of i schizophrenic disorder 295 ii other psychotic disorder 293 81 293 82 295 40 295 70 297 1 297 3 298 9 iii mood disorder 293 83 296 22 296 23 296 24 296 32 296 33 296 34 296 40 296 42 296 43 296 44 296 52 296 53 296 54 296 62 296 63 296 64 296 7296 80 296 89 iv amnestic disorder 294 0 294 8 v disorder due to a general medical condition 293 0 310 1 TN No 08016 Approved Effective 7 01 08 NOW Supersedes TN No 03 004

SUPPLEMENT 1B to Attachment 3 1A Service 19 Case Management Services Chronically Mentally III Adults Page 2 vi pervasive developmental disorder not otherwise specified 299 80 when not accompanied by mental retardation or vii anxiety disorder 300 01 300 21 300 3 or viii posttraumatic stress disorder 309 81 d has a DSMIVTR diagnosis of personality disorder 301 00 301 20 301 22 301 4 301 50 301 6 301 81 301 82 301 83 or 301 90 and e has ongoing functioning difficulties because of the mental illness for a period of at least six months or for an obviously predictable period over six months as indicated by at least two of the following i a medical professional with prescriptive authority has determined that medication is necessary to control the symptoms of mental illness ii the person is unable to work in a full time competitive situation because of mental illness iii the person has been determined to be disabled due to mental illness by the social security administration or iv the person maintains a living arrangement only with ongoing supervision is homeless or is at imminent risk of homelessness due to mental illness or v the person has had or will predictably have repeated episodes of decompensation Targeted case management services will not be furnished to a otherwise qualified individuals who reside in a Medicaid certified IMD except for the time period required to assist in transition to community services and TN No 08016 Approved Effective 7 01 08 N Wr Supersedes E TN No 03 004

SUPPLEMENT 1B to Attachment3 1A VOW Service 19 Case Management Services Chronically Mentally III Adults Page 3 b persons who receive case management services under a home and communitybased waiver program authorized under Section 1915 c of the Social Security Act For case management services provided to individuals in medical institutions Olmstead letter 3 Target group is comprised of individuals transitioning to a community setting and case management services will be made available for up to 180 consecutive days of the covered stay in the medical institution X Case management services are coordinated with and do not duplicate activities provided as a part of developmental institutional services and discharge planning activities B Areas of State in which Services will be provided Adults with Severe Disabling Mental Illness X Entire State Only in the following geographic areas authority of section 1915 g 1 of the Act is invoked to provide services less than statewide C Comparability of Services Severe Disabling Mental Illness SDMIJ Services are provided in accordance with section 1902 a 10 B of the Act X Services are not comparable in amount duration and scope TN No 08016 Approved Effective 7 01 08 VOW Supersedes TN No 03 004

SUPPLEMENT 1B to Attachment 3 1A Service 19 Case Management Services Chronically Mentally III Adults Page 4 D Definition of Services DRA 2001 SMD Severe Disabling Mental Illness SDMI Case management is defined as Services that assist individuals eligible under the Medicaid State Plan in gaining access to needed medical social educational and other services Case Management activities includes the following assistance 1 Case management services include a comprehensive assessment and reassessment at least once every 90 days of an 1 W eligible individual to determine service needs including activities that focus on needs identification determination of the need for any medical educational social or other services These assessment activities include the following i taking client history ii identifying the needs of the individual and completing related documentation and iii gathering necessary information from other sources such as family members medical providers social workers and educators if necessary to make a complete assessment of the eligible individual b development and periodic revision of a specific care plan based on the information collected through the assessment that i specific goals and actions to address the medical social and educational and other services needed by the eligible individual TN No 08016 Approved Effective 7 01 08 Supersedes FEB TN No 03 004 t

SUPPLEMENT 1B to Attachment 3 1A Service 19 Case Management Services Chronically Mentally III Adults Page 5 ii includes activities such as ensuring the active participation of the eligible individual and working with the individual or the individual sauthorized health care decision maker and others to develop those goals and iii identifies a course of action to respond to the assessed needs of the eligible individual c referral and related activities such as making referrals and scheduling appointments for the individual to help the eligible individual obtain needed services including activities to help link the individual with medical social and educational providers or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan and d monitoring and followup activities including activities and contacts to ensure that the care plan is effectively implemented and addresses the needs of the eligible individual Activity may be with the individual family members service providers or other entities or individuals and conducted as frequently as necessary and at least once every 90 days to help determine whether the following conditions are met i services are being furnished in accordance with the individual s care plan ii services in the care plan are adequate to meet the needs of the individual iii there are changes in the needs or status of the eligible individual Monitoring and followup activities include making necessary adjustments in the care plan and service arrangements with providers 2 case management services for adults with severe disabling mental illness are case management services provided by a licensed mental health center in accordance with these rules and the provisions of Title 50 chapter 5 part 2 MCA 3 Case management may include contacts with noneligible individuals that are directly related to the identification of the eligible individual s needs and care for the purpose of helping the eligible individual access services identifying needs and supports to assist the eligible individual in obtaining services providing case managers TN No 08016 Approved Effective 7 01 08 Supersedes TN No 03004

Mrr SUPPLEMENT 1B to Attachment3 1A Service 19 Case Management Services Chronically Mentally III Adults Page 6 with useful feedback alerting case managers to changes in the eligible individual s needs and averting crisis 4 Case management does not include the Non Medicaid individuals can receive outreach application and referral activities however these activities are not allowable as case management services rather they are an administrative function Direct medical services including counseling or the transportation or escort of consumers Duplicate payments that are made to public agencies or private entities under the State Plan and other program authorities The writing recording or entering case notes for the consumer sfile Coordination of the investigation of any suspected abuse neglect andor exploitation cases Travel to and from client activities and Any service less than 8 minutes duration if it is the only service provided that day and any service that does not incorporate the allowable targeted case management components even if written into the individualized care plan 6 Case management reimbursement requirements include those described in 1 through 5 and the following a case managers must inform eligible individuals they have the right to refuse case management at the time of eligibility determination and annually thereafter at the time of reassessment and b providers must document in the case record that the individual has been informed and if the individual has refused services Crisis Intervention Adults with Severe Disabling Mental Illness SDMI TN No 08016 Approved Effective 7 01 08 Supersedes TN No 03 004 REF

SUPPLEMENT 1B to 14 r Attachment 3 1A Service 19 Case Management Services Chronically Mentally III Adults Page 7 Targeted case management services for adults with SDMI must be provided by a licensed mental health center For a mental health center to be licensed it must provide to its clients crises telephone services Mental health centers must document case management plans for adults with SDMI at least every 90 days and must include a crisis response plan F Qualifications of Providers Adults with Severe Disablinq Mental Illness SDMI Qualified providers are required to be licensed Mental Health Centers with a case NW management endorsement Mental Health Centers providing TCM services to adults with SDMI must have a program supervisor and employ case managers who have a bachelor sdegree in a human services field with at least one year of full time experience serving individuals with SDMI Individuals with other educational background who have developed the necessary skills may also be employed as case managers The mental health center scase management position description must contain equivalency provisions The availability of case management services may not be made contingent upon a client swillingness to receive other services TN No 08016 Approved Effective 7 01 08 W Supersedes TN No 03004 FLD

SUPPLEMENT 1B to Attachment 3 1A Service 19 Case Management Services Chronically Mentally III Adults Page 8 G Freedom Of Choice Adults with Severe Disabling Mental Illness SDMI The State assures that the provision of case management services will not restrict an individual sfree choice of providers in violation of section 1902 a 23 of the Act Eligible recipients will have free choice of the providers of case management services within the specified geographic area identified in this plan Eligible recipients will have free choice of the providers of other medical care under the plan Providers must be licensed by the State of Montana A mental health center may not condition a client saccess to one of its services upon the client s receipt of another services provided by the mental health center 4W 1 Freedom of Choice The State chooses to limit provider choice per section 1915 g 1 of the Social Security Act the Act 2 Freedom of Choice Exception X Target group consists of eligible individuals with developmental disabilities or with chronic mental illness Providers are limited to providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental illness receive needed services H Access to Services Adults with Severe Disabling Mental Illness SDMI The State assures that TN No 08016 Approved Effective 7 01 08 Supersedes TN No 03 004 Fi r

SUPPLEMENT 1B to NW Attachment 3 1A Service 19 Case Management Services Chronically Mentally III Adults Page 9 Case management services will be provided in a manner consistent with the best interest of recipients and will not be used to restrict an individual s access to other services under the plan section 1902 a 19 Individuals will not be compelled to receive case management services condition receipt of case management services on the receipt of other Medicaid services or condition receipt of other Medicaid services on receipt of case management services section 1902 a 19 Providers of case management services do not exercise the agency sauthority to authorize or deny the provision of other services under the plan 42 CFR 431 10 e For plans that provide case management services to assist individuals who reside in medical institutions to transition to the community the State makes the following assurances The State assures that the amount duration and scope of the case management activities would be documented in an individual splan of care which includes case management activities prior to and postdischarge to facilitate a successful transition to the community The State assures that case management is only provided by and reimbursed to licensed mental health centers The State assures that Federal Financial Participation is only available to community providers and will not be claimed on behalf of an individual until discharge from the medical institution and enrollment in community services TN No 08016 Approved Effective 7 01 08 Supersedes TN No 03004 1

SUPPLEMENT 1B to Attachment3 1A Service 19 Case Management Services Chronically Mentally III Adults Page 10 I Case Records Adults with Severe Disabling Mental Illness SDMI All providers of service must maintain records which fully demonstrate the extent nature and medical necessity of services and items provided to Montana Medicaid recipients The records must support the fee charged or payment sought for the services and items and demonstrate compliance with all applicable requirements Case management providers must maintain case records that document for all individuals receiving case management services as follows i the name of the individual ii the dates of the case management services iii the name of the provider agency and the person providing the case management services iv the nature content units of the case management services received and whether goals specified in the care plan have been achieved v whether the individual has declined services in the care plan vi the need for and occurrences of coordination with other case managers vii a timeline for obtaining needed services viii a timeline for reevaluation of the plan J Limitations Adults with Severe Disabling Mental Illness SDMI Case Management does not include TN No 08016 Approved Effective 7 01 08 r Supersedes TN No 03 004 G 201 1

SUPPLEMENT 1B to Attachment 3 1A Mrrr Service 19 Case Management Services Chronically Mentally III Adults Page 11 Non Medicaid individuals can receive outreach application and referral activities however these activities are not allowable as case management services rather they are an administrative function Direct medical services including counseling or the transportation or escort of consumers Duplicate payments that are made to public agencies or private entities under the State Plan and other program authorities The writing recording or entering case notes for the consumer sfile Coordination of the investigation of any suspected abuse neglect andor exploitation cases Travel to and from client activities and Any service less than 8 minutes duration if it is the only service provided that day and any service that does not incorporate the allowable targeted case management components even if written into the individualized care plan VI W TN No 08016 Approved Effective 7 01 08 QW Supersedes TN No 03004 20 It

SUPPLEMENT 1B to Attachment 3 113 Service 19 Case Management Services Chronically Mentally III Adults Page 1 A Target Group Adults with Severe Disabling Mental Illness SDMI Targeted Case Management TCM services are furnished to assist Medicaid eligible adults with severe disabling mental illness SDMI in gaining access to needed medical social educational and other services Services are provided by a licensed mental health center with a license endorsement permitting the mental health center to provide case management services An adult with severe disabling mental illness is defined as A person who is 18 or more years of age that the person meets the requirements of 4 a b c or d The person must also meet the requirements of4 e The person a has been involuntarily hospitalized for at least 30 consecutive days because of a mental disorder at Montana State Hospital Warm Springs campus at least once b has recurrent thoughts of death recurrent suicidal ideation or a suicide attempt or a specific plan for committing suicide c has a DSMIVTR diagnosis of i schizophrenic disorder 295 ii other psychotic disorder 293 81 293 82 295 40 295 70 297 1 297 3 298 9 iii mood disorder 293 83 296 22 296 23 296 24 296 32 296 33 296 34 296 40 296 42 296 43 296 44 296 52 296 53 296 54 296 62 296 63 296 64 296 7 296 80 296 89 iv amnestic disorder 294 0 294 8 v disorder due to a general medical condition 293 0310 1 TN No C8016 Approved Effective 7 01 08 Supersedes TN No 03004

SUPPLEMENT 1B to Attachment 3 16 Service 19 Case Management Services Chronically Mentally III Adults Page 2 vi pervasive developmental disorder not otherwise specified 299 80 when not accompanied by mental retardation or vii anxiety disorder 300 01 300 21 300 3 or viii posttraumatic stress disorder 309 81 d has a DSMIVTR diagnosis of personality disorder 301 00 301 20 301 22 301 4 301 50 301 6 301 81 301 82 301 83 or 301 90 and e has ongoing functioning difficulties because of the mental illness for a period of at least six months or for an obviously predictable period over six months as indicated by at least two of the following i a medical professional with prescriptive authority has determined that medication is necessary to control the symptoms of mental illness ii the person is unable to work in a fulltime competitive situation because of mental illness iii the person has been determined to be disabled due to mental illness by the social security administration or iv the person maintains a living arrangement only with ongoing supervision is homeless or is at imminent risk of homelessness due to mental illness or v the person has had or will predictably have repeated episodes of decompensation Targeted case management services will not be furnished to a otherwise qualified individuals who reside in a Medicaid certified IMD except for the time period required to assist in transition to community services and TN No 08016 Approved Effective 7 01 08 Supersedes TN No 030041

SUPPLEMENT 1B to Attachment 3 16 Service 19 Case Management Services Chronically Mentally III Adults Page 3 b persons who receive case management services under a home and communitybased waiver program authorized under Section 1915 c of the Social Security Act For case management services provided to individuals in medical institutions Olmstead letter 3 Target group is comprised of individuals transitioning to a community setting and case management services will be made available for up to 180 consecutive days of the covered stay in the medical institution X Case management services are coordinated with and do not duplicate activities provided as a part of developmental institutional services and discharge planning activities B Areas of State in which Services will be provided Adults with Severe Disabling Mental Illness X Entire State Only in the following geographic areas authority of section 1915 g 1 of the Act is invoked to provide services less than statewide C Comparability of Services Severe Disabling Mental Illness SDMI Services are provided in accordance with section 1902 a 10 B of the Act X Services are not comparable in amount duration and scope TN No 08016 Approved Effective 7 01 08 Supersedes TN No 03004 1FJ 111

SUPPLEMENT 1B to Attachment 3 113 Service 19 Case Management Services Chronically Mentally III Adults Page 4 D Definition of Services DRA 2001 SMD Severe Disabling Mental Illness SDMI Case management is defined as Services that assist individuals eligible under the Medicaid State Plan in gaining access to needed medical social educational and other services Case Management activities includes the following assistance 1 Case management services include a comprehensive assessment and reassessment at least once every 90 days of an eligible individual to determine service needs including activities that focus on needs identification determination of the need for any medical educational social or other services These assessment activities include the following i taking client history ii identifying the needs of the individual and completing related documentation and iii gathering necessary information from other sources such as family members medical providers social workers and educators if necessary to make a complete assessment of the eligible individual b development and periodic revision of a specific care plan based on the information collected through the assessment that i specific goals and actions to address the medical social and educational and other services needed by the eligible individual TN No 08016 Approved Effective 7 01 08 Supersedes TN No 03 004

SUPPLEMENT 1B to Attachment 3 113 Service 19 Case Management Services Chronically Mentally III Adults Page 5 ii includes activities such as ensuring the active participation of the eligible individual and working with the individual or the individual sauthorized health care decision maker and others to develop those goals and iii identifies a course of action to respond to the assessed needs of the eligible individual c referral and related activities such as making referrals and scheduling appointments for the individual to help the eligible individual obtain needed services including activities to help link the individual with medical social and educational providers or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan and d monitoring and followup activities including activities and contacts to ensure that the care plan is effectively implemented and addresses the needs of the eligible individual Activity may be with the individual family members service providers or other entities or individuals and conducted as frequently as necessary and at least once every 90 days to help determine whether the following conditions are met i services are being furnished in accordance with the individual s care plan ii services in the care plan are adequate to meet the needs of the individual iii there are changes in the needs or status of the eligible individual Monitoring and followup activities include making necessary adjustments in the care plan and service arrangements with providers 2 case management services for adults with severe disabling mental illness are case management services provided by a licensed mental health center in accordance with these rules and the provisions of Title 50 chapter 5 part 2 MCA 3 Case management may include contacts with noneligible individuals that are directly related to the identification of the eligible individual s needs and care for the purpose of helping the eligible individual access services identifying needs and supports to assist the eligible individual in obtaining services providing case managers TN No 08016 Approved Effective 7 01 08 Supersedes TN No 03004k t

SUPPLEMENT 113 to Attachment 3 1B Service 19 Case Management Services Chronically Mentally III Adults Page 6 with useful feedback alerting case managers to changes in the eligible individual s needs and averting crisis 4 Case management does not include the Non Medicaid individuals can receive outreach application and referral activities however these activities are not allowable as case management services rather they are an administrative function Direct medical services including counseling or the transportation or escort of consumers Duplicate payments that are made to public agencies or private entities under the State Plan and other program authorities The writing recording or entering case notes for the consumer sfile Coordination of the investigation of any suspected abuse neglect andor exploitation cases Travel to and from client activities and Any service less than 8 minutes duration if it is the only service provided that day and any service that does not incorporate the allowable targeted case management components even if written into the individualized care plan 6 Case management reimbursement requirements include those described in 1 through 5 and the following a case managers must inform eligible individuals they have the right to refuse case management at the time of eligibility determination and annually thereafter at the time of reassessment and b providers must document in the case record that the individual has been informed and if the individual has refused services Crisis Intervention Adults with Severe Disabling Mental Illness SDMI TN No 08016 Approved Effective 7 01 08 Supersedes TN No 03004

SUPPLEMENT 1B to Attachment 3 16 Service 19 Case Management Services Chronically Mentally III Adults Page 7 Targeted case management services for adults with SDMI must be provided by a licensed mental health center For a mental health center to be licensed it must provide to its clients crises telephone services Mental health centers must document case management plans for adults with SDMI at least every 90 days and must include a crisis response plan F Qualifications of Providers Adults with Severe Disabling Mental Illness SDMI Qualified providers are required to be licensed Mental Health Centers with a case management endorsement Mental Health Centers providing TCM services to adults with SDMI must have a program supervisor and employ case managers who have a bachelor sdegree in a human services field with at least one year of full time experience serving individuals with SDMI Individuals with other educational background who have developed the necessary skills may also be employed as case managers The mental health center scase management position description must contain equivalency provisions The availability of case management services may not be made contingent upon a client s willingness to receive other services G Freedom Of Choice Adults with Severe Disabling Mental Illness SDMI The State assures that the provision of case management services will not restrict an individual sfree choice of providers in violation of section 1902 a 23 of the Act TN No C8016 Approved Effective 7 O1 08 Supersedes TN No 03004

SUPPLEMENT 1B to Attachment 3 16 Service 19 Case Management Services Chronically Mentally III Adults Page 8 Eligible recipients will have free choice of the providers of case management services within the specified geographic area identified in this plan Eligible recipients will have free choice of the providers of other medical care under the plan Providers must be licensed by the State of Montana A mental health center may not condition a client s access to one of its services upon the client s receipt of another services provided by the mental health center 1 Freedom of Choice The State chooses to limit provider choice per section 1915 g 1 of the Social Security Act the Act 2 Freedom of Choice Exception X Target group consists of eligible individuals with developmental disabilities or with chronic mental illness Providers are limited to providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental illness receive needed services H Access to Services Adults with Severe Disabling Mental Illness SDMI The State assures that TN No 08016 Approved Effective 7 01 08 Supersedes TN No 03004 FE

SUPPLEMENT 1B to Attachment 3 113 Service 19 Case Management Services Chronically Mentally III Adults Page 9 Case management services will be provided in a manner consistent with the best interest of recipients and will not be used to restrict an individual saccess to other services under the plan section 1902 a 19 Individuals will not be compelled to receive case management services condition receipt of case management services on the receipt of other Medicaid services or condition receipt of other Medicaid services on receipt of case management services section 1902 a 19 Providers of case management services do not exercise the agency s authority to authorize or deny the provision of other services under the plan 42 CFR 431 10 e For plans that provide case management services to assist individuals who reside in medical institutions to transition to the community the State makes the following assurances The State assures that the amount duration and scope of the case management activities would be documented in an individual s plan of care which includes case management activities prior to and postdischarge to facilitate a successful transition to the community The State assures that case management is only provided by and reimbursed to licensed mental health centers The State assures that Federal Financial Participation is only available to community providers and will not be claimed on behalf of an individual until discharge from the medical institution and enrollment in community services TN No 08016 Approved Effective W01 08 Supersedes TN No 03004

SUPPLEMENT 1B to Attachment 3 16 Service 19 Case Management Services Chronically Mentally III Adults Page 10 I Case Records Adults with Severe Disablinq Mental Illness SDMI All providers of service must maintain records which fully demonstrate the extent nature and medical necessity of services and items provided to Montana Medicaid recipients The records must support the fee charged or payment sought for the services and items and demonstrate compliance with all applicable requirements Case management providers must maintain case records that document for all individuals receiving case management services as follows i the name of the individual ii the dates of the case management services iii the name of the provider agency and the person providing the case management services iv the nature content units of the case management services received and whether goals specified in the care plan have been achieved v whether the individual has declined services in the care plan vi the need for and occurrences of coordination with other case managers vii a timeline for obtaining needed services viii a timeline for reevaluation of the plan J Limitations Adults with Severe Disabling Mental Illness SDMI Case Management does not include TN No 08016 Approved Effective 7 01 08 Supersedes TN No 03004 FED

SUPPLEMENT 1B to Attachment 3 113 Service 19 Case Management Services Chronically Mentally III Adults Page 11 Non Medicaid individuals can receive outreach application and referral activities however these activities are not allowable as case management services rather they are an administrative function Direct medical services including counseling or the transportation or escort of consumers Duplicate payments that are made to public agencies or private entities under the State Plan and other program authorities The writing recording or entering case notes for the consumer s file Coordination of the investigation of any suspected abuse neglect andor exploitation cases Travel to and from client activities and Any service less than 8 minutes duration if it is the only service provided that day and any service that does not incorporate the allowable targeted case management components even if written into the individualized care plan TN No 08016 Approved Effective 701 08 Supersedes TN No 03004 E 12 Gi1

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO_ 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION i

| 2. STATE Montana

1, TRANSMITTAL NUMBER: 09-011

3. PROGRAM IDENTIFICATION: Title XIX of the Social Security Act (Medicaid)

TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE

July 1, 2009

5. TYPE OF PLAN MATERIAL (Check One):

([] NEW STATE PLAN

(1) AMENDMENT TO BE CONSIDERED AS NEW PLAN

{J AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal jor each amendment)

6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 438.112, 1902(a)(52), 1902(e)(1), and 1925 of the Act

7, FEDERAL BUDGET IMPACT:

a. FFY 2009 $ 158,950 b. FFY 2010 $ 635,800 c.FFY 2011 $635,800

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: —

Supplement 12b to Attachment 2.6-A, page 1

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/f Applicable): n/a - new page

' 10. SUBJECT OF AMENDMENT:

Amendment to extend Medicaid eligibility under TMA for an initial period of 12 months

11. GOVERNOR'S REVIEW (Check One): {_] GOVERNOR’S OFFICE REPORTED NO COMMENT (] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED (NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED:

12. SIGNATURE OF STATE ay OFFICIAL:

13. TYPED NAME: Mary is Dalton

14. TITLE: State Medicaid Director

15, DATE SUBMITTED:

16. RETURN TO:

Montana Dept. of Public Health and Human Services Mary E. Dalton

State Medicaid Director

Attn: Jo Thompson

PO Box 4210

Helena, MT 59604

Ite 3-09 FOR REGIONAL OFFICE USE ONLY - - 17. DATERECEIVED: 4) - 2 _p . 18. DATE APPROVED: a $ [09 OF ~ revisipas Nob [09

! PLAN APPROVED — ONE COPY AFFACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL:

Flr 109

POD OO OFFICIAL:

21.T Din NAME ‘ 22. TLE: : } xf eet 0. Alken Acsecise Kegon) Adiinis trator

FORM HCFA-179 (07-92)

Revision: SUPPLEMENT 12b TO ATTACHMENT 2.6-A Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Montana

ELIGIBILITY UNDER SECTION 1925 OF THE ACT TRANSITIONAL MEDICAL ASSISTANCE

The State covers low-income families and children for Transitional Medical Assistance (TMA) under section 1925 of the Social Security Act (the Act). This coverage is provided for families who no longer qualify under section 1931 of the Act due to increased earned income, or working hours, from the caretaker relative’s employment, or due to the loss of a time-limited earned income disregard (42 CFR 435.112, 1902(a)(52), 1902(e)(1), and 1925 of the Act)

The amount, duration and scope of services for this coverage group are specified in Section 3.5 this State plan.

For Medicaid eligibility to be extended through TMA, families must have been Medicaid eligible under section 1931 (months of retroactive eligibility may be used to meet this requirement):

X During at least 3 of the 6 months immediately preceding the month in which the family become ineligible under section 1931.

For fewer that 3 of the 6 previous months immediately preceding the month in which the family became ineligible under section 1931. Specify:

The State extends Medicaid eligibility under TMA for an initial period of:

6 months. For TMA eligibility to continue into a second 6-month extension period, the family must meet the reporting, technical and income eligibility requirements specified in section 1925(b) of the Act.

X 12 months. Section 1925(b) does not apply for a second 6-month extension period.

The State collects and reports participation information to the Department of Health and Human Services as required by section 1925(g) of the Act, in accordance with the format, timing and frequency specified by the Secretary and makes such information publicly available.

TN: 09-011 Approval Date / Wi b/ og Effective Date _July 1, 2009 Superseded TN: NEW

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

1600 Broadway, Suite 700

Denver, CO 80202-4967 CENTERS for MEDICARE & MEDICAID SERVICES

Region VIII

November 6, 2009

Ms. Mary Dalton

Medicaid & Health Services Manager

Montana Department of Public Health & Human Services 111 North Sanders, Room 301

P.O. Box 4210

Helena, MT 59604

Re: Approval of State Plan Amendment (SPA) MT 09-011

Dear Ms. Dalton:

We have received Montana’s State Plan Amendment 09-011. The intent of this SPA is to provide for an initial 12 months of Transitional Medical Assistance (TMA) for eligible individuals.

CMS has completed its review of this SPA. Please be advised that the amendment is approved with an effective date of July 1, 2009.

Sincerely,

/s/ Richard C. Allen

Associate Regional Administrator Divisions of Medicaid and Children’s Health Operations

Cc: Duane Preshinger

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

May 31, 2012

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-12-002

Dear Ms Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 12-002. This amendment provides assurances that Montana will comply and implement section 6401 of the Affordable Care Act (ACA) as promulgated under 42 CFR 455 subpart E in reverence to provider screening and enrollment.

Please be informed that this State Plan Amendment was approved on May 30, 2012 with an effective date of April 1, 2012. We will be sending the CMS-179 and the amended plan page(s) in a separate e-mail.

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Anna Whiting Sorrell Duane Preshinger Jo Thompson

r Page 1 of 2 STATE PLAN UNDER TITLE XD OF THE SOCIAL SECURITY ACT State Territory Montana Citation 4 46 Provider Screening and Enrollment 1902 a 77 The State Medicaid agency gives the following assurances 1902 a 39 1902 kk P L I I 1 148 and P L III 152 42 CFR 455 PROVIDER SCREENING Subpart E XAssures that the State Medicaid agency complies with the process for screening providers under section 1902 a 39 1902 a 77 and 1902 kk of the Act 42 CFR 455 410 ENROLLMENT AND SCREENING OF PROVIDERS X Assures enrolled providers will be screened in accordance with 42 CFR 455 400 et seq Assures that the State Medicaid agency requires all ordering or referring physicians or other professionals to be enrolled under the State plan or under a waiver of the Plan as a participating provider 42 CFR 455 412 VERIFICATION OF PROVIDER LICENSES X Assures that the State Medicaid agency has a method for verifying providers licensed by a State and that such providers licenses have not expired or have no current limitations 42 CFR 455 414 REVALIDATION OF ENROLLMENT X Assures that providers will be revalidated regardless of provider type at least every 5 years 42 CFR 455 416 TERMINATION OR DENIAL OF ENROLLMENT XAssures that the State Medicaid agency will comply with section 1902 a 39 of the Act and with the requirements outlined in 42 CFR 455 416 for all terminations or denials of provider enrollment 42 CFR 455 420 REACTIVATION OF PROVIDER ENROLLMENT XAssures that any reactivation of a provider will include rescreening and payment of application fees as required by 42 CFR 455 460 TN 12002 Approval Date Effective Date04 01 2012 Supersedes New

Page 2 of 2 42 CFR 455 422 APPEAL RIGHTS XAssures that all terminated providers and providers denied enrollment as a result of the requirements of 42 CFR 455 416 will have appeal rights available under procedures established by State law or regulation 42 CFR 455 432 SITE VISITS X Assures that preenrollment and postenrollment site visits of providers who are in moderate or high risk categories will occur 42 CFR 455 434 CRIMINAL BACKGROUND CHECKS Assures that providers as a condition of enrollment will be required to consent to criminal background checks including fingerprints if required to do so under State law or by the level of screening based on risk of fraud waste or abuse for that categoryof provider 42 CFR 455 436 FEDERAL DATABASE CHECKS XAssures that the State Medicaid agency will perform Federal database checks on all providers or any person with an ownership or controlling interest or who is an agent or managing employee of the provider 42 CFR 455 440 NATIONAL PROVIDER IDENTIFIER XAssures that the State Medicaid agency requires the National Provider Identifier of any ordering or referring physician or other professional to be specified on any claim for payment that is based on an order or referral of the physician or other professional 42 CFR 455 450 SCREENING LEVELS FOR MEDICAIDPROVIDERS XAssures that the State Medicaid agency complies with 1902 a 77 and 1902 kk of the Act and with the requirements outlined in 42 CFR 455 450 for screening levels based upon the categorical risk level determined for a provider 42 CFR 455 460 APPLICATION FEE Assures that the State Medicaid agency complies with the requirements for collection of the application fee set forth in section 18660 2 Cof the Act and 42 CFR 455 460 42 CFR 455 470 TEMPORARY MORATORIUM ON ENROLLMENT OF NEW PROVIDERS OR SUPPLIERS X Assures that the State Medicaid agency complies with any ternporary moratorium on the enrollment of new providers or provider types imposed by the Secretary undersection 1866 j 7and 1902 kk 4of the Act subject to any determination by the State and written notice to the Secretary that such a temporary moratorium would not adversely impact beneficiaries access to medical assistance TN 12 002 Approval Date5 Effective Date D410I12012 Supersedes New

DEPARTMENT OF HEALTH AND HUMANSERVICES FORM APPROVED HEALTHCARE FINANCING ADMINISTRATION OMB N0 09380193 TRANSMITTAL AND NOTICE OF APPROVAL OF ITRANSMITTAL NUMBER 2 STATE STATE MATERIAL 12002 Montana 3 PROGRAM IDENTIFICATION Title XIX ofthe FOR HEALTH CARE FINANCING ADMINISTRATION Social SecurityAct Medicaid TO REGIONAL ADMINISTRATOR 4PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES Aril 1 2012 5 TYPE OF PLAN MATERIAL CheckOne NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENTSep arale Transmi la or each amendment 6 FEDERAL STATUTEIREGULATION CITATION 7 FEDERAL BUDGET IMPACT 42 CFR Parts 455 Subpart E a FFY 12 0 c FFY 13 0 8 PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9 PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Citation 4 46 OR ATTACHMENT ljAppficable Pages 12 10 SUBJECT OF AMENDMENT Update to SP reflecting implementation of Provider Screening and Enrollment 11 GOVERNOR SREVIEW Check One GOVERNOR SOFFICE REPORTED NO COMMENT OTHER AS SPECIFIED COMMENTS OF GOVERNOR S OFFICE ENCLOSED Single Agency Director Review NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12 SIGNATURE OF STATE AGENCY OFFICIAL 16 RETURN TO Montana Dept of Public Health and Human Services 13 TYPED NAME M E Dalton Mary E Dalton State Medicaid Director 14 TITLE State Medicaid Director Attn 3o Thompson PO Box 4210 M DATE SUBMITTED 5 3 1 Or 3 Helena MT 59604 FOR REGIONAL OFFICE USE ONLY 17 DATE RECEIVED March 23 2012 18 DATE APPROVED May 30 2012 PLAN APPROVED ONE COPY ATTACHED 19 EFFECTIVE DATE OF APPROVED MATERIAL April 1 2012 20 SIGNATURE OF REGIONAL OFFICIAL 21 TYPED NAME Richard C Allen 22 TITLE Associate Regional Administrator 23 REMARKS FORM CMS179

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

September 23, 2013

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-13-009

Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-009. This SPA increases rates 2% and changes the date the agency's rates were set for TCM, Adult Mental Health.

Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Anna Whiting Sorrell Duane Preshinger Jo Thompson

SUPPLEMENT 1 B to Attachment 3. 1 A Service 19 Case Management Services Chronically Mentally Ill Adults Page 1 A. Target Group: Adults with Severe Disabling Mental Illness ( SDMI Targeted Case Management ( TCM) services are furnished to assist Medicaid eligible adults with severe disabling mental illness ( SDMI) in gaining access to needed medical, social, educational, and other services. Services are provided by a licensed mental health center with a license endorsement permitting the mental health center to provide case management services. An adult with severe disabling mental illness is defined as: A person who is 18 or more years of age that the person meets the requirements of (4)( a), ( b), ( c) or ( d). The person must also meet the requirements of (4)( e). The person: a) has been involuntarily hospitalized for at least 30 consecutive days because of a mental disorder at Montana State Hospital Warm Springs campus) at least once; b) has recurrent thoughts of death, recurrent suicidal ideation, or a suicide attempt, or a specific plan for committing suicide; c) has a DSM- IV-TR diagnosis of: i) schizophrenic disorder ( 295); ii) other psychotic disorder ( 293. 81, 293. 82, 295. 40, 295. 70, 297. 1, 297. 3, 298. 9); iii) mood disorder ( 293. 83, 296. 22, 296. 23, 296. 24, 296. 32, 296. 33, 296. 34, 296. 40, 296. 42, 296. 43, 296. 44, 296. 52, 296. 53, 296. 54., 296. 62, 296. 63, 296. 64, 296. 7, 296. 80, 296. 89); iv) amnestic disorder ( 294. 0, 294. 8); v) disorder due to a general medical condition ( 293. 0, 310. 1); TN No. 13- 009 Approved SEP 2' 3 2013 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT 1B to Attachment 3. 1 A Service 19 Case Management Services Chronically Mentally Ill Adults Page 2 vi) pervasive developmental disorder not otherwise specified 299. 80) when not accompanied by mental retardation; or vii) anxiety disorder ( 300. 01, 300. 21, 300. 3); or viii) posttraumatic stress disorder ( 309. 81); d) has a DSM- IV-TR diagnosis of personality disorder ( 301. 00, 301. 20, 301. 22, 301. 4, 301. 50, 301. 6, 301. 81, 301. 82, 301. 83, or 301. 90); and e) has ongoing functioning difficulties because of the mental illness for a period of at least six months or for an obviously predictable period over six months, as indicated by at least two of the following: i) a medical professional with prescriptive authority has determined that medication is necessary to control the symptoms of mental illness; ii) the person is unable to work in a full- time competitive situation because of mental illness; iii) the person has been determined to be disabled due to mental illness by the social security administration; or iv) the person maintains a living arrangement only with ongoing supervision, is homeless, or is at imminent risk of homelessness due to mental illness; or v) the person has had or will predictably have repeated episodes of decompensation. Targeted case management services will not be furnished to: a. otherwise qualified individuals who reside in a Medicaid- certified IMD, and TN No. 13- 009 Approved SEP 2 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT 1B to Attachment 3. 1 A Service 19 Case Management Services Chronically Mentally Ill Adults Page 3 b. persons who receive case management services under a home and community- based waiver program authorized under Section 1915 ( c) of the Social Security Act. For case management services provided to individuals in medical institutions: [Olmstead letter # 3] Target group is comprised of individuals transitioning to a community setting and case- management services will be made available for up to 180 consecutive days of the covered stay in the medical institution. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions. X Case management services are coordinated with and do not duplicate activities provided as a part of developmental institutional services and discharge planning activities. B. Areas of State in which Services will be provided: Adults with Severe Disabling Mental Illness X) Entire State: Only in the following geographic areas ( authority of section 1915 ( g) ( 1) of the Act is invoked to provide services less than statewide). TN No. 13- 009 Approved SEp 2,,3 2013 Effective 7/ 01%2013 Supersedes TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 A Service 19 Case Management Services Chronically Mentally Ill Adults Page 4 C. Comparability of Services: Severe Disabling Mental Illness ( SDMI) Services are provided in accordance with section 1902 a) ( 10) ( B) of the Act. X) Services are not comparable in amount, duration, and scope. D. Definition of Services: [ DRA & 2001 SMD] Severe Disabling Mental Illness ( SDMI) Case management is defined as: Services that assist individuals eligible under the Medicaid State Plan in gaining access to needed medical, social, educational and other services. Case Management activities includes the following assistance: 1) Case management services include: a) comprehensive assessment and reassessment at least once every 90 days of an eligible individual to determine service needs, including activities that focus on needs identification determination of the need for any medical, educational, social, or other services. These assessment activities include the following: i) taking client history; ii) identifying the needs of the individual, and completing related documentation; and iii) gathering necessary information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to make a complete assessment of the eligible individual. b) development ( and periodic revision) of a specific care plan based on the information collected through the assessment that: TN No. 13- 009 Approved Effective 7/ 01/ 2013 Supersedes P 2, 3 201 TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 A Service 19 Case Management Services Chronically Mentally Ill Adults Page 5 i) specific goals and actions to address the medical, social and educational, and other services needed by the eligible individual; ii) includes activities such as ensuring the active participation of the eligible individual and working with the individual ( or the individual' s authorized health care decision maker) and others to develop those goals; and iii) identifies a course of action to respond to the assessed needs of the eligible individual. c) referral and related activities ( such as making referrals and scheduling appointments for the individual) to help the eligible individual obtain needed services, including activities to help link the individual with medical, social and educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and d) monitoring and follow- up activities, including activities and contacts to ensure that the care plan is effectively implemented and addresses the needs of the eligible individual. Activity may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and at least once every 90 days, to help determine whether the following conditions are met: : i) services are being furnished in accordance with the individual' s care plan; ii) services in the care plan are adequate to meet the needs of the individual; TN No. 13- 009 Approved SEP 2, 3 2013 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 A Service 19 Case Management Services Chronically Mentally Ill Adults Page 6 iii) there are changes in the needs or status of the eligible individual. Monitoring and follow- up activities include making necessary adjustments in the care plan and service arrangements with providers. 2) case management services for adults with severe disabling mental illness are case management services provided by a licensed mental health center in accordance with these rules and the provisions of Title 50, chapter 5, part 2, MCA 3) Case management may include contacts with noneligible individuals that are directly related to the identification of the eligible individual' s needs and care, for the purpose of helping the eligible individual access services, identifying needs and supports to assist the eligible individual in obtaining services, providing case managers with useful feedback, alerting case managers to changes in the eligible individual' s needs, and averting crisis. 4) " Case management" does not include the: Non- Medicaid individuals can receive outreach, application, and referral activities, however, these activities are not allowable as case management services, rather they are an administrative function. Direct medical services including counseling or the transportation or escort of consumers; Duplicate payments that are made to public agencies or private entities under the State Plan and other program authorities; The writing, recording or entering case notes for the consumer' s file; Coordination of the investigation of any suspected abuse, neglect, and/ or exploitation cases; Travel to and from client activities; and Any service less than 8 minutes duration if it is the only service TN No. 13- 009 Approved Effective 7/ 01/ 2013 Supersedes SEp 2, 3 2013 TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 A Service 19 Case Management Services Chronically Mentally 111 Adults Page 7 provided that day and any service that does not incorporate the allowable targeted case management components, even if written into the individualized care plan. 6) Case management reimbursement requirements include those described in ( 1) through ( 5) and the following: a) case managers must inform eligible individuals they have the right to refuse case management at the time of eligibility determination and annually thereafter at the time of reassessment; and b) providers must document in the case record that the individual has been informed and if the individual has refused services. F. Qualifications of Providers: Adults with Severe Disabling Mental Illness ( SDMI) Qualified providers are required to be licensed Mental Health Centers with a case management endorsement. Mental Health Centers providing TCM services to adults with SDMI must have a program supervisor and employ case managers who have a bachelor's degree in a human services field with at least one year of full- time experience serving individuals with SDMI. Individuals with other educational background, who have developed the necessary skills, may also be employed as case managers. The mental health center' s case management position description must contain equivalency provisions. The availability of case management services may not be made contingent upon a client' s willingness to receive other services. TN No. 13- 009 Approved Effective 7/ 01/ 2013 Supersedes SEP 113 2913 TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 A Service 19 Case Management Services Chronically Mentally Ill Adults Page 8 G. Freedom Of Choice: Adults with Severe Disabling Mental Illness ( SDMI) The State assures that the provision of case management services will not restrict an individual' s free choice of providers in violation of section 1902( a)( 23) of the Act. Eligible recipients will have free choice of the providers of case management services within the specified geographic area identified in this plan. Eligible recipients will have free choice of the providers of other medical care under the plan. Providers must be licensed by the State of Montana. A mental health center may not condition a client' s access to one of its services upon the client' s receipt of another services provided by the mental health center. 1. Freedom of Choice: The State chooses to limit provider choice per section 1915 g)( 1) of the Social Security Act ( the Act). 2. Freedom of Choice Exception: X Target group consists of eligible individuals with chronic mental illness. Providers are limited to providers of case management services capable of ensuring that individuals with chronic mental illness receive needed services. H. Access to Services: Adults with Severe Disabling Mental Illness ( SDMI) The State assures that: TN No. 13- 009 Approved SEP 2. 3 201& Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 A Service 19 Case Management Services Chronically Mentally Ill Adults Page 9 Case management services will be provided in a manner consistent with the best interest of recipients and will not be used to restrict an individual' s access to other services under the plan; [ section 1902 ( a)( 19)] Individuals will not be compelled to receive case management services, condition receipt of case management services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management services; [ section 1902 ( a)( 19)] Providers of case management services do not exercise the agency' s authority to authorize or deny the provision of other services under the plan. [ 42 CFR 431. 10( e)] For plans that provide case management services to assist individuals who reside in medical institutions to transition to the community, the State makes the following assurances:] The State assures that the amount, duration, and scope of the case management activities would be documented in an individual' s plan of care which includes case management activities prior to and post- discharge, to facilitate a successful transition to the community. The State assures that case management is only provided by and reimbursed to licensed mental health centers. The State assures that Federal Financial Participation is only available to community providers and will not be claimed on behalf of an individual until discharge from the medical institution and enrollment in community services. TN No. 13- 009 Approved SEP 2 3 2013 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT l B to Attachment 3. 1 A Service 19 Case Management Services Chronically Mentally Ill Adults Page 10 I. Case Records: Adults with Severe Disabling Mental Illness ( SDMI) All providers of service must maintain records which fully demonstrate the extent, nature and medical necessity of services and items provided to Montana Medicaid recipients. The records must support the fee charged or payment sought for the services and items and demonstrate compliance with all applicable requirements. Case management providers must maintain case records that document for all individuals receiving case management services as follows: i) the name of the individual. ii) the dates of the case management services. iii) the name of the provider agency and the person providing the case management services. iv) the nature, content, units of the case management services received and whether goals specified in the care plan have been achieved. v) whether the individual has declined services in the care plan. vi) the need for, and occurrences of, coordination with other case managers. vii) a timeline for obtaining needed services. viii) a timeline for reevaluation of the plan. J. Limitations: TN No. 13- 009 Approved Effective 7/ 01/ 2013 Supersedes SEP 2, 3 2013 TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 A Service 19 Case Management Services Chronically Mentally Ill Adults Page 11 Case management does not include, and Federal Financial Participation FFP) is not available in expenditures for, services defined in § 440. 169 when the case management activities are an integral and inseparable component of another covered Medicaid service ( State Medicaid Manual ( SMM) 4302. F). Case management does not include, and Federal Financial Participation FFP) is not available in expenditures for, services defined in § 440. 169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. ( 42 CFR 441. 18( c)) FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that is included in an individualized education program or individualized family service plan consistent with § 1903( c) of the Act. 1902( a)( 25) and 1905( c)) TN No. 13- 009 Approved SEP 213 2013 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT l B to Attachment 3. 1 B Service 19 Case Management Services Chronically Mentally III Adults Page 1 A. Target Group: Adults with Severe Disabling Mental Illness ( SDMI) Targeted Case Management ( TCM) services are furnished to assist Medicaid eligible adults with severe disabling mental illness ( SDMI) in gaining access to needed medical, social, educational, and other services. Services are provided by a licensed mental health center with a license endorsement permitting the mental health center to provide case management services. An adult with severe disabling mental illness is defined as: A person who is 18 or more years of age that the person meets the requirements of ( 4)( a), ( b), ( c) or ( d). The person must also meet the requirements of ( 4)( e). The person: a) has been involuntarily hospitalized for at least 30 consecutive days because of a mental disorder at Montana State Hospital Warm Springs campus) at least once; b) has recurrent thoughts of death, recurrent suicidal ideation, or a suicide attempt, or a specific plan for committing suicide; c) has a DSM- IV-TR diagnosis of: i) schizophrenic disorder ( 295); ii) other psychotic disorder ( 293. 81, 293. 82, 295. 40, 295. 70, 297. 1, 297. 3, 298. 9); iii) mood disorder ( 293. 83, 296. 22, 296. 23, 296. 24, 296. 32, 296. 33, 296. 34, 296. 40, 296. 42, 296. 43, 296. 44, 296. 52, 296. 53, 296. 54., 296. 62, 296. 63, 296. 64, 296. 7, 296. 80, 296. 89); iv) amnestic disorder ( 294. 0, 294. 8); v) disorder due to a general medical condition ( 293. 0, 310. 1); TN No. 13- 009 Approved SEP 2.3 2013 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 B Service 19 Case Management Services Chronically Mentally Ill Adults Page 2 vi) pervasive developmental disorder not otherwise specified 299. 80) when not accompanied by mental retardation; or vii) anxiety disorder ( 300. 01, 300. 21, 300. 3); or viii) posttraumatic stress disorder ( 309. 81); d) has a DSM- IV-TR diagnosis of personality disorder ( 301. 00, 301. 20, 301. 22, 301. 4, 301. 50, 301. 6, 301. 81, 301. 82, 301. 83, or 301. 90); and e) has ongoing functioning difficulties because of the mental illness for a period of at least six months or for an obviously predictable period over six months, as indicated by at least two of the following: i) a medical professional with prescriptive authority has determined that medication is necessary to control the symptoms of mental illness; ii) the person is unable to work in a full- time competitive situation because of mental illness; iii) the person has been determined to be disabled due to mental illness by the social security administration; or iv) the person maintains a living arrangement only with ongoing supervision, is homeless, or is at imminent risk of homelessness due to mental illness; or v) the person has had or will predictably have repeated episodes of decompensation. Targeted case management services will not be furnished to: a. otherwise qualified individuals who reside in a Medicaid- certified IMD, and TN No. 13- 009 Approved SEp 2.;3 2019 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 B Service 19 Case Management Services Chronically Mentally Ill Adults Page 3 b. persons who receive case management services under a home and community- based waiver program authorized under Section 1915 ( c) of the Social Security Act. For case management services provided to individuals in medical institutions: [Olmstead letter # 3] Target group is comprised of individuals transitioning to a community setting and case- management services will be made available for up to 180 consecutive days of the covered stay in the medical institution. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions. X Case management services are coordinated with and do not duplicate activities provided as a part of developmental institutional services and discharge planning activities. B. Areas of State in which Services will be provided: Adults with Severe Disabling Mental Illness X) Entire State: Only in the following geographic areas ( authority of section 1915 ( g) ( 1) of the Act is invoked to provide services less than statewide). TN No. 13- 009 Approved- SIP 213 2013 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 B Service 19 Case Management Services Chronically Mentally Ill Adults Page 4 C. Comparability of Services: Severe Disabling Mental Illness ( SDMI) Services are provided in accordance with section 1902 a) ( 10) ( B) of the Act. X) Services are not comparable in amount, duration, and scope. D. Definition of Services: [ DRA & 2001 SMD] Severe Disabling Mental Illness ( SDMI) Case management is defined as: Services that assist individuals eligible under the Medicaid State Plan in gaining access to needed medical, social, educational and other services. Case Management activities includes the following assistance: 1) Case management services include: a) comprehensive assessment and reassessment at least once every 90 days of an eligible individual to determine service needs, including activities that focus on needs identification determination of the need for any medical, educational, social, or other services. These assessment activities include the following: i) taking client history; ii) identifying the needs of the individual, and completing related documentation; and iii) gathering necessary information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to make a complete assessment of the eligible individual. b) development ( and periodic revision) of a specific care plan based on the information collected through the assessment that: TN No. 13- 009 Approved SEP 27.3 2013 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT l B to Attachment 3. 1 B Service 19 Case Management Services Chronically Mentally Ill Adults Page 5 i) specific goals and actions to address the medical, social and educational, and other services needed by the eligible individual; ii) includes activities such as ensuring the active participation of the eligible individual and working with the individual ( or the individual' s authorized health care decision maker) and others to develop those goals; and iii) identifies a course of action to respond to the assessed needs of the eligible individual. c) referral and related activities ( such as making referrals and scheduling appointments for the individual) to help the eligible individual obtain needed services, including activities to help link the individual with medical, social and educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and d) monitoring and follow- up activities, including activities and contacts to ensure that the care plan is effectively implemented and addresses the needs of the eligible individual. Activity may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and at least once every 90 days, to help determine whether the following conditions are met: i) services are being furnished in accordance with the individual' s care plan; ii) services in the care plan are adequate to meet the needs of the individual; iii) there are changes in the needs or status of the eligible individual. Monitoring and follow- up activities include making necessary adjustments in the care plan and service arrangements with providers. 2) case management services for adults with severe disabling mental illness are case management services provided by a licensed mental health center in accordance with these rules and the provisions of Title 50, chapter 5, part 2, MCA TN No. 13- 009 ApprovedSEP 2, 3 2013 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 B Service 19 Case Management Services Chronically Mentally III Adults Page 6 3) Case management may include contacts with noneligible individuals that are directly related to the identification of the eligible individual' s needs and care, for the purpose of helping the eligible individual access services, identifying needs and supports to assist the eligible individual in obtaining services, providing case managers with useful feedback, alerting case managers to changes in the eligible individual' s needs, and averting crisis. 4) " Case management" does not include the: Non- Medicaid individuals can receive outreach, application, and referral activities, however, these activities are not allowable as case management services, rather they are an administrative function. Direct medical services including counseling or the transportation or escort of consumers; Duplicate payments that are made to public agencies or private entities under the State Plan and other program authorities; The writing, recording or entering case notes for the consumer's file; Coordination of the investigation of any suspected abuse, neglect, and/ or exploitation cases; Travel to and from client activities; and Any service less than 8 minutes duration if it is the only service provided that day and any service that does not incorporate the allowable targeted case management components, even if written into the individualized care plan. 6) Case management reimbursement requirements include those described in ( 1) through ( 5) and the following: a) case managers must inform eligible individuals they have the right to refuse case management at the time of eligibility determination and annually thereafter at the time of reassessment; and b) providers must document in the case record that the individual has been informed and if the individual has refused services. TN No. 13- 009 Approved 5.EP 2 3 2013 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT I B to Attachment 3. 1 B Service 19 Case Management Services Chronically Mentally III Adults Page 7 F. Qualifications of Providers: Adults with Severe Disabling Mental Illness ( SDMI) Qualified providers are required to be licensed Mental Health Centers with a case management endorsement. Mental Health Centers providing TCM services to adults with SDMI must have a program supervisor and employ case managers who have a bachelor's degree in a human services field with at least one year of full- time experience serving individuals with SDMI. Individuals with other educational background, who have developed the necessary skills, may also be employed as case managers. The mental health center's case management position description must contain equivalency provisions. The availability of case management services may not be made contingent upon a client' s willingness to receive other services. G. Freedom Of Choice: Adults with Severe Disabling Mental Illness ( SDMI) The State assures that the provision of case management services will not restrict an individual' s free choice of providers in violation of section 1902( a)( 23) of the Act. Eligible recipients will have free choice of the providers of case management services within the specified geographic area identified in this plan. Eligible recipients will have free choice of the providers of other medical care under the plan. TN No. 13- 009 Approved lip 2 :3 2013 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 B Service 19 Case Management Services Chronically Mentally Ill Adults Page 8 Providers must be licensed by the State of Montana. A mental health center may not condition a client's access to one of its services upon the client' s receipt of another services provided by the mental health center. 1. Freedom of Choice: The State chooses to limit provider choice per section 1915 q)( 1) of the Social Security Act ( the Act). 2. Freedom of Choice Exception: X Target group consists of eligible individuals with chronic mental illness. Providers are limited to providers of case management services capable of ensuring that individuals with chronic mental illness receive needed services. H. Access to Services: Adults with Severe Disabling Mental Illness ( SDMI) The State assures that: TN No. 13- 009 Approved SEP 2 3 2013 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 B Service 19 Case Management Services Chronically Mentally Ill Adults Page 9 Case management services will be provided in a manner consistent with the best interest of recipients and will not be used to restrict an individual' s access to other services under the plan; [ section 1902 ( a)( 19)] Individuals will not be compelled to receive case management services, condition receipt of case management services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management services; [ section 1902 ( a)( 19)] Providers of case management services do not exercise the agency' s authority to authorize or deny the provision of other services under the plan. [ 42 CFR 431. 10( e)] For plans that provide case management services to assist individuals who reside in medical institutions to transition to the community, the State makes the following assurances:] The State assures that the amount, duration, and scope of the case management activities would be documented in an individual' s plan of care which includes case management activities prior to and post- discharge, to facilitate a successful transition to the community. The State assures that case management is only provided by and reimbursed to licensed mental health centers. The State assures that Federal Financial Participation is only available to community providers and will not be claimed on behalf of an individual until discharge from the medical institution and enrollment in community services. TN No. 13- 009 Approved SEP 2 3 2013 Effective 7/ 01/ 2013 Supersedes TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 B Service 19 Case Management Services Chronically Mentally III Adults Page 10 I. Case Records: Adults with Severe Disabling Mental Illness ( SDMI) All providers of service must maintain records which fully demonstrate the extent, nature and medical necessity of services and items provided to Montana Medicaid recipients. The records must support the fee charged or payment sought for the services and items and demonstrate compliance with all applicable requirements. Case management providers must maintain case records that document for all individuals receiving case management services as follows: i) the name of the individual. ii) the dates of the case management services. iii) the name of the provider agency and the person providing the case management services. iv) the nature, content, units of the case management services received and whether goals specified in the care plan have been achieved. v) whether the individual has declined services in the care plan. vi) the need for, and occurrences of, coordination with other case managers. vii) a timeline for obtaining needed services. viii) a timeline for reevaluation of the plan. TN No. 19- 009 Approved Effective 7/ 01/ 2013 Supersedes SEP 2, 3 200 TN No. 08- 016

SUPPLEMENT 1 B to Attachment 3. 1 B Service 19 Case Management Services Chronically Mentally Ill Adults Page 11 J. Limitations: Case management does not include, and Federal Financial Participation FFP) is not available in expenditures for, services defined in § 440. 169 when the case management activities are an integral and inseparable component of another covered Medicaid service ( State Medicaid Manual ( SMM) 4302. F). when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. ( 42 CFR 441. 18( c)) FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that is included in an individualized education program or individualized family service plan consistent with § 1903( c) of the Act. 1902( a)( 25) and 1905( c)) TN No. 13- 009 Approved SEP 2. 3 2013iffective 7/ 01/ 2013 Supersedes TN No. 08- 016

Page 1 of 1 Attachment 4. 1913 Methods& Standards for Establishing Payment Rates Service 19 c Targeted Case Management Services for Adults with Severe Disabling Mental Illness( SDMI) The Montana Medicaid service array includes Targeted Case Management( TCM) for adults with severe disabling mental illness( SDMI). The TCM program for adults with SDMI is administered by the Addictive and Mental Disorders Division (AMDD), Mental Health Services Bureau ( MHSB). Services are provided by a licensed mental health center with a license endorsement permitting the mental health center to provide case management services. TCM services for adults with SDMI will be reimbursed on a fee per unit of service basis. A unit of service is a period of 15 minutes. Reimbursement for TCM services for adults with severe disabling mental illness will be based on the lowest of: the providers' actual charge for the service or the Department' s fee schedule. Unless otherwise noted in the plan payment for these services fee schedule rates are the same for both governmental and private providers of TCM for adults with severe disabling mental illness. The agency' s rates were set as of the date on the Attachment 4. 1913 Introduction Page and are published at www. mtmedicaid. or€,. TN 13- 009 Approved: SEP 2 3 W3 Effective 7/ 1/ 13 Supersedes: 11- 035

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB N0. 11938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13- 009 Montana the FOR: HEALTH CARE• FINANCING ADMINISTRATION 3 PROGRAM IDENTIFICATION: Title XdI of Social Security Act( Medicaid) TO: REGIONAL ADMINISTRATOR PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT fSe .arate Transmittal or each amendment ..... 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 42 CRF Parts 431, 440, and 441 a. FFY 2013( three months) $ 1, 750,490 CMS 2237- IFC a. FFY 2014 7, 166,871 c. FFY 2015( nine months) $ 5,508,521 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SE& 1_6_N OR ATTACHMENT( IfApplicable): Attachment 4. 198 Supplement 1C to Attachment 4.19B Service 19c Service 19c Targeted Case Management for Adults with Severe Disabling Mental Targeted Case Management for Adults with Severe Disabling Illness( SDMI) Mental Illness( SDMI) 10. SUBJECT OF AMENDMENT: Increase the rate approximately 2% and update the date of the fee schedule on the Attachment 4. 19B Introduction Page. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT X OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED Single Agency Director Review. NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN Montana Dept. of Public Health and Human Services 13. TYPED NAME: MA E. Dalton Mary E. Dalton State Medicaid Director TITLE: State Medicaid Director Attn: Jo Thompson PO Box 4210 15. DATE SUBMITTED: o?9 - 13 Helena, MT 59604 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: 80 2,1 2013 PLAN APPROVED—ONE COPY ATTACHED EFFECTIVE DATE OF APPROVED AfATERIAL. 20 F NAL OFFICIAL: 21. TYPED NAME: q72 9 Kc lr 23. REMARKS: FORM t4rFA- 179 M7-971

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

September 23, 2013

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-13-015

Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-015. This SPA increases rates 2% and changes the date the agency's rates were set for Optometrists’ Services.

Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Anna Whiting Sorrell Duane Preshinger Jo Thompson

Page 1 of 2 Attachment 4. 19E Methods & Standards for Establishing Payment Rates, Service 6. b Optometrists' Services MONTANA I. Reimbursement for Optometric Services shall be: A. The lower of: 1. The provider' s usual and customary charge for the service; or 2. Reimbursement provided in accordance with the methodology described in Number II. II. The Department' s fee schedule for Optometric Services is determined in the following hierarchical order: RBRVS; Medicare rate; Medicaid fee; or by report:.. A. Resource Based Relative Value Scale ( RBRVS) Methodology: 1. In accordance with the Resource Base Relative Value Scale RBRVS) methodology, by multiplying Medicare' s Relative Value Units ( RVU) , which is numeric, by the Montana Medicaid specific conversion factor, which is a dollar amount, to equal a fee. Specific to Montana Medicaid, there is an ability to multiply the fee times a policy adjustor ( either plus or minus) to affect the fee. 2. " Resource based relative value scale ( RBRVS)" means the version of the Medicare resource based relative value scale contained in the physicians' Medicare Physician Fee Schedule adopted by the Centers for Medicare and Medicaid Services ( CMS) . 3. " Relative value unit (RVU)" means a numerical value assigned in the resource based relative value scale to each procedure code used to bill for services provided by a health care provider. The relative value unit assigned to a particular code expresses the relative effort and expense expended by a provider in providing one service as compared with another service. 4. The RVU' s are adopted from the RBRVS. For the services for which the RBRVS does not specify RVU' s, the department sets those RVU' s as follows: The RVUs for a Medicaid covered service are calculated as follows: i. If Medicare sets RVU' s, the Medicare RVU' s are applicable; ii. If Medicare does not set_ RVU' s but Medicaid sets RVUs, the Medicaid RVUs are set in the following manner: TN 13- 015 Approved 1Up 2-2 2013 Effective 07/ 01/ 2013 Supersedes: 12- 019

Page 2 of 2 Attachment 4. 19B Methods & Standards for Establishing Payment Rates, Service 6. b Optometrists' Services MONTANA A) convert the existing dollar value of a fee to an RVU value; B) evaluate the RVU of similar services and adding an RVU value; or C) convert the average by report dollar value of a fee to an RVU value. B. Medicare Rates: Optometrists will. be paid by the applicable Medicare rate for supplies and goods where the RBRVS methodology is not applicable. Medicare rates are updated effective the 1st day of the quarter based on the Medicare quarterly adjustment. C. Medicaid Fee: Payment is made using the applicable State developed Medicaid fee based on claims history data for medications, supplies or goods where the RBRVS or Medicare fee schedule is not applicable. D. For those rare instances when the RBRVS, Medicare rate or Medicaid fee methodology does not apply, reimbursement will be ' by report' By report' means paying a percentage of billed charges. The percentage is derived by dividing the previous state fiscal year' s total Medicaid reimbursement for services included in the RBRVS by the previous state fiscal year' s total Medicaid billings. The ' by report' methodology will end by 6/ 30/ 14. III. The agency' s rates were set as of the date on the Attachment 4. 19B Introduction Page. Reimbursement is set at the current Medicare rates in effect as of the date of service. All rates are published on the agency' s website www. mtmed-i.cai.d. org. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private providers. TN 13- 015 Approved SEP 2. 3 2013 Effective 07/ 01/ 2013 Supersedes: 12- 019

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB N0. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13- 015 Monlana 3. PROGRAM IDENTIFICATION: Tide XIX of the 1 FOR: HEALTH CARE FINANCING ADMINISTRATION Social Security Act( Medicaid) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 07/01/2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN EIAMENDMENT TO BE CONSIDERED AS NEW PLAN Z AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT( Separate Transmittalfor each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 1902(a)( 30)( A) a. FFY 2013 6,928 b. FFY 2014 27, 852 c. FFY 2014 27,852 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SEcri6R-- Page( s) 1 of 1 and 2 of 2 OR ATTACHMENT( IfApplicable): Attachment 4.19B Page( s) 1 of 1 and 2 of 2 Methods& Standards for Establishing Payment Rates Attachment 4.19B I Service 6.b Methods& Standards for Establishing Payment Rates Optometrists' Services Service 6. b Optometrists' Services SUBJECT OF AMENDMENT: Amend Service 6b, Optometrists' Services to increase fees 2% and to update the date of the fee schedule. 11. dOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 1 12. SIGNATURE OF -STATE AGENCY OFFICIAL: 16. RETURN TO: Montana Dept. of Public Health and Human Services 13. TYPED NAME: Nlary' o Dalton Mary E. Dalton State Medicaid Director 14. TITLE: State Medicaid Director Attn: Jo lbompson PO Box 4210 Helena, MT 59604 15. DATE SUBMITTED: 17—,DA OMM PATF,," y 7 1, tin 7, ONE N EITE FFIqAL- il.Typp 7 7 j FORM T4rFA- 1 70( W-9'?1

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

September 23, 2013

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-13-016

Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-016. This SPA increases rates 2% and changes the date the agency's rates were set for Physical Therapy Services.

Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Anna Whiting Sorrell Duane Preshinger Jo Thompson

Page 1 of 2 Attachment 4 . 19B, Methods & Standards or Establishing Payment Rates, Service lla, Physical Therapy Services MONTANA I. Reimbursement for Physical Therapy Services shall be: A. The lower of: 1. The provider' s * usual and customary charge for the service; or 2. The reimbursement provided in accordance with the methodology described in Section II. II. The Department' s fee schedule for Physical Therapy Services is determined: A. In accordance with the Resource Base Relative Value Scale RBRVS) methodology, by multiplying Medicare' s Relative Value Units ( RVU) , which is numeric, by the Montana Medicaid specific conversion factor, which is a dollar amount, to equal a fee. Specific to Montana Medicaid, there is an ability to multiply the fee times a policy adjuster ( either plus or minus) to affect the fee. B. " Resource based relative value scale ( RBRVS) " means the version of the Medicare resource based relative value scale contained in the physicians' Medicare Physician Fee Schedule adopted by the Centers for Medicare and Medicaid Services ( CMS) . C. " Relative value unit ( RVU) " means a numerical value assigned in the resource based relative value scale to each procedure code used to bill for services provided by a health care provider. The relative value unit assigned to a particular code expresses the relative effort and expense expended by a provider in providing one service as compared with another service. TN 13- 016 Approved UP 1-3 X13 Effective 07/ 01/_ 2013 Supersedes 12- 016

Page 2 of 2 Attachment 4 . 19B Methods & Standards For Establishing Payment Rates, Service ll. a, Physical Therapy Services D. The RVUs are adopted from the RBRVS. For services for which the RBRVS does not specify RVUs, the Department sets those RVUs as follows: 1) The RVUs for a Medicaid covered service are calculated as follows: i) if Medicare sets RVUs, the Medicare RVUs are applicable; ii) if Medicare does not set RVUs but Medicaid sets RVUs, the Medicaid RVUs are set in the following manner: A) convert the existing dollar value of a fee to an RVU value; B) evaluate the RVU of similar services and assign an RVU value; or C) convert the average by report dollar value of a fee to an RVU value. E. If there is not a Medicare RVU or Medicaid history data, reimbursement will be ` by report' , `By report' means paying a percentage of billed charges. The percentage is derived by dividing the previous state fiscal year' s total Medicaid reimbursement for services included in the RBRVS by the previous state fiscal year' s total Medicaid billings. The ` by report' methodology will end by 6/ 30/ 14 . F. The agency' s rates were set as of the date on the Attachment 4 . 19B Introduction Page and are published on the agency' s website www. mtmedicaid. org. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private providers. TN 13- 016 Approved SEP_ 2_3 M3 Effective 07/ 01/ 2013 Supersedes 12- 016

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13- 016 Montana 1 3. PROGRAM IDENTIFICATION: Title XIX of the FOR: HEALTH CARE FINANCING ADMINISTRATION Social Security Act( Medicaid) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 07/01/ 2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT( Separate Transmittalfor each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: N/A a. FFY 2013 6,043 b. FFY 2014 24,290 c. FFY 2015 24,290 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 1 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION I Page(s) I of I and 2 of 2 E OR ATTACHMENT( IfApplicable): Attachment 4. 19E Page(s) 1 of 1 and 2 of 2 Methods& Standards of Establishing Payment Rules Attachment 4.19B Service I I a Methods& Standards of Establishing Payment Rules Physical Therapy Services Service 11a Physical Therapy Services 10. SUBJECT OF AMENDMENT: Amend Physical Therapy to increase fees 2% and update the date of the fee schedule. G0V--ER"N--0— R—'S REVIEW( Check One): F- 1 GOVERNOR' S OFFICE REPORTED NO COMMENT Z OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: y)-,'aAA1'-i- k0iJav- Montana Dept. of Public Health and Human Services 13. TYPED NAME: Mary alton Mary E. Dalton State Medicaid Director 14. TITLE: State Medicaid Director Attn: Jo Thompson PO Box 4210 15. DATE SUBMITTED: Helena, MT 59604 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: f 18. DATE APPROVED* 3 PLAN APPROVED—ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERLAL t3N F OFFICIAL: 21. TYPED NAME: a. mr& 23. REMARKS: FORM i4rFA- 179( m-w)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

September 23, 2013

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-13-017

Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-017. This SPA increases rates 2% and changes the date the agency's rates were set for Occupational Therapy Services.

Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Anna Whiting Sorrell Duane Preshinger Jo Thompson

Page 1 of 2 Attachment 4. 19B Methods & Standards For Establishing Payment Rates, Service ll. b, Occupational Therapy Services MONTANA I. Reimbursement for Occupational Therapy Services shall be: A. The lower of: 1. The provider' s * usual and customary charge for the service, or 2. The reimbursement provided in accordance with the methodology described in Section II. The Department' s fee schedule for Occupational Therapy Services is determined: A. In accordance with the Resource Base Relative Value Scale RBRVS) methodology, by multiplying Medicare' s Relative Value Units ( RVU) , which is numeric, by the Montana Medicaid specific conversion factor, which is a dollar amount, to equal, a fee. Specific to Montana Medicaid, there is an ability to multiply the fee times a policy adjuster ( either plus or minus) to affect the fee. B. " Resource based relative value scale ( RBRVS) " means the version of the Medicare resource based relative value scale contained in the physicians' Medicare Physician Fee Schedule adopted by the Centers for Medicare and Medicaid Serv.i.ces ( CMS) . C. " Relative value unit ( RVU) " means a numerical value assigned in the resource based relative value scale to each procedure code used to bill for services provided by a health care provider. The relative value unit assigned to a particular code expresses the relative effort and expense expended by a provider in providing one service as compared with another service. TN 13- 017 Approved _ Wk 2. 3 2013 Effective 07/ 01/ 201_:3 Supersedes TN 12- 017 s

Page 2 of 2 Attachment 4. 19B Methods & Standards For Establishing Payment Rates, Service Zl. b, Occupational Therapy Services D. The RVUs are adopted from the RBRVS. For services for which the RBRVS does not specify RVUs, the Department sets those RVUs as follows: 1) The RVUs for a Medicaid covered service are calculated as follows: i) if Medicare sets RVUs, the Medicare RVUs are applicable; ii) if Medicare does not set RVUs but Medicaid sets RVUs, the Medicaid RVUs are set in the following manner: A) convert the existing dollar value of a fee to an RVU value; B) evaluate the RVU of similar services and assign an RVU value; or C) convert the average by report dollar value of a fee to an RVU value. E. If there is not a Medicare RVU or Medicaid history data, reimbursement will be ` by report' , `By report' means paying a percentage of billed charges. The percentage is derived by dividing the previous state fiscal year' s total Medicaid reimbursement for services included in the RBRVS by the previous state fiscal year' s total Medicaid billings. The ' by report' methodology will end by 6/ 30/ 14. F. The agency' s rates were set as of the date on the Attachment 4. 19E Introduction Page and are published on the agency' s website www. mtmedicaid. org. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private providers. TN 13- 017 Approved SEP 2 , 3 2013 Effective 07/ 01/ 2013_ Supersedes TN 12- 017

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13-017 Montana 3 FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: Title XIX of the Social Security Act( Medicaid) m. ............_____..._."_........",, ,,.,,,,,,..°.................___.__."_......,,.,._,_.,.,._ ......... _......__.... j TO: REGIONAL ADMINISTRATOR t 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 07101/ 2013 i DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS A_N AMENDMENT( Separate Transmittal or each amendment r,.__........_ _.._ ......"_ . .._..._..._ L___.._..__ 6. FEDERAL STKI'UTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 1902( a)( 30)(A) a. FFY 2013 3,576 b. FFY 2014 14,377 E c. FFY 2015 14,377 4. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Pages 2 of 2 OR ATTACHMENT( IfApplicable): Attachment 4. 19B Pages 2 of 2 Methods& Standards for Establishing Payment Rates Attachment 4. 19B Service lib Methods& Standards for Establishing Payment Rates Occupational Therapy Services Service 11.b Occupational Therapy Services 10. SUBJECT OF AMENDMENT: Increase Occupational Therapy rates 2% and update the date of the fee schedule. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Montana Dept. of Public Health and Human Services 13. TYPED NAME: Mary E. E61ton Mary E. Dalton State Medicaid Director 14. TITLE: State Medicaid Director Attn: Jo Thompson PO Box 4210 15. DATE SUBMITTED: Helena, MT 59604 y 3'., AN 17, DA7 < : 2 mL: rte:• $ r T < q l ° w W411 y...' v ; iP": w' r', / iik5r''. 4' y N£ s ( 3€ ; a a. a'„ k: , , a,, z s y' i.W Y+ c. S>v°' cr rr. ga." a, i s'• , r.,' s.'„'} 67 oz Up, ae t m 3 ' k'" s'" s-§;. s a• ` s4 g'Up, a b. 6{ g p'° k v, h" ar,'#, u iq sY.• x" a s.'` L'- xs L 49 N° s y a 4ft" 4 toga° s . a ' aa t? % v..'t P S' f° re,;' •` ;, sg ` v,. R1, aw ° ° s' q; i •'#, M`€ v tia z iv . bs sxm f zaaasm a. A g s y^ E° s rx° , i 3 ` b , ga } 4 rs as •. x5 4ak 3^ sa S' r' ," ky }. be a aw Yi, a b' a• R°,„a a * r FORM T4rFA_174 M7_991

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

September 23, 2013

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-13-018

Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-018. This SPA increases rates 2% and changes the date the agency's rates were set for Speech Therapy and Audiology Services.

Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Anna Whiting Sorrell Duane Preshinger Jo Thompson

Page 1 of 2 Attachment 4. 108, Methods & Standards For Establishina Payment Rates, Service 11. c Speech Therapy & Audiology Services MONTANA Reimbursement for Speech Therapy Services and Audiology Services shall be: A. For Speech Therapy Services the 'Lower of; 1. The provider' s * usual and customary charge for the service; or 2. The reimbursement provided in accordance with the methodology described in Section II. B. For Audiology Services the lower of: 1. The provider' s * usual and customary charge for the service; or 2. The reimbursement provided in accordance with the methodology described in Section II, or 3. 100% of the Medicare region D allowable fee. Ii. The Department' s fee schedule for Speech Therapy Services and Audiology Services is determined; A. In accordance with the Resource Base Relative Value Scale RBRVS) methodology, by multiplying Medicare' s Relative Value Units ( RVU) , which is numeric, by the Montana Medicaid specific conversion factor, which is a dollar amount, to equal. a fee. Specific to Montana Medicaid, there is an ability to multiply the fee times a policy adjuster ( either plus or minus) to affect the fee. B. " Resource based relative value scale ( RBRVS) " means the version of the Medicare resource based relative value scale contained in the physicians' Medicare Physician Fee Schedule adopted by the Centers for Medicare and Medicaid Services ( CMS) . C. " Relative value unit ( RVU) " means a numerical value assigned in the resource based relative value scale to each procedure code used to bill. for services provided by a health care provider. The relative value unit assigned to a particular code expresses the relative effort and expense expended by a provider in providing one service as compared with another service. TN 13- 018 Approved__ySV 21 2013 Effective 07/ 01. 12013 Supersedes 12- 018

Page 2 of 2 Attachment 9. 19B, Methods & Standards For Establishing Payment Rates, Service ll. c Speech Therapy & Audiology Services MONTANA D. The RVUs are adopted from the RBRVS. For services for which the RBRVS does not specify RVUs, the Department sets those RVUs as follows: 1) The RVUs fcr a Medicaid covered service are calculated as follows: i) if Medicare sets RVUs, the Medicare RVUs are applicable; ii_) if Medicare does riot set RVUs but Medicaid sets RVUs, the Medicaid RVUs are set in the following manner: A) cc,nvert the existing dollar value of a fee to an RVU value; B) evaluate the RVU of similar services and assign an RVU value; or C) convert the average by report dollar value of a fee to an RVU value. E. If there is Ilot a Medicare RVU or Medicaid history data, reimbursement will be ' by report' , ' By report' means paying a percentage of billed charges. The percentage is derived by dividing the previous state fiscal year' s total Medicaid reimbursement for services included in the RBRVS by the previous state fiscal year' s total Medicaid billings. The by report' methodology will. end by 6/ 30/ 19. F. The agency' s rates were set as of the date on the Attachment 9. 19B Introduction Page and are published on the agency' s website www. mtmedicaid. org. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private providers. TN 13- 018 Approved Crp 2, 3 2013 Effective 07_/01/ 2013 Supersedes 12- 018

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 1--- 1. ... I............-_.... TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13- 018 Montana FOR- HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: Title XIX of the I Social Security Act( Medicaid) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION July 1, 2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT( Separate Transmittal or 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 1902(a)( 30)( A) a. FFY 2013 5, 447 b. FFY 2014 21,896 c. FFY 2014 21, 896 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN—SECTION Page( s) 1 of I and 2 of 2 OR ATTACHMENT( IfApplicable): Attachment 4. 19E Page(s) I of I and 2 of 2 Methods& Standards for Establishing Payment Rates Attachment 4. 19B Service 1 Lc Methods& Standards for Establishing Payment Rates ii Speech Therapy and Audiology Services Service 11. c Speech Therapy and Audiology Services 10. SUBJECT OF AMENDMENT: Increase Speech Therapy and Audiology fees 2% and update the date of the fee schedule. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT ED OTHER, AS SPECIFIED: SINGLE COMMENTS OF GOVERNOR' S OFFICE ENCLOSED AGENCY DIRECTOR REVIEW F- 1 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Montana Dept. of Public Health and Human Services 13. TYPED NAME: Mary E. on Mary E. Dalton State Medicaid Director 14. TITLE: State Medicaid Director Attn: Jo Thompson PO Box 4210 Helena, MT 59604 15. DATE SUBMITTED n113 7 VQRJA5110NAL21E U ONLY 17. fiAla R PAI WRQVED SEP. z 3 O4111) ONE GDPY ATWOW RLAN APM m Or" VE T 20, DrA UOf APPROVED7&f RLAL QAL-, 7, WED 21. T 114 09 : x ! bme Ho FORM MCFA- 170 ffl7-Q') 1

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

September 23, 2013

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-13-019

Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-019. This SPA increases rates 2% and changes the date the agency's rates were set for Dental, Denturist, Denture and Dental Hygienist Services.

Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Anna Whiting Sorrell Duane Preshinger Jo Thompson

Page 1 of 2 Attachment 4. 19B Methods and Standards for Establishing Payment Rates Service 10 Dental Services MONTANA i . Reimbursement for Dental Services shall be the lowest of the following; a. The provider' s usual and customary charge for the service. b. The Department' s fee schedule for dental services. 2. The Department' s fee schedule is calculated as follows: a. Dental procedures are identified through the following process: 1) Procedures identified through ADA/ CDT coding manual; or 2) Dental procedures identified by the Department not identified in the current ADA/ CDT. b. Definitions: Relative Value Unit ( RVU) The unit value assigned to a specific procedure code published in c. ( 1) . Relative Value for Dentists (RVD) : a value given to each procedure code outlined in 2. c. ( 1) ( b) ( i) . C. Reimbursement rates are set by one of the following methods: 1) For procedures listed in the " Relative Values for Dentists" published biennially by Relative Value Studies, Tncorporated, reimbursement rates shall be determined using the following methodology: a) The fee for a covered service shall be the amount determined by multiplying the ( RVU) by the conversion factor specifies: in 2. c. ( 1) ( b) ( iii) . b) The conversion factor and provider fees for dentists, dental hygienists, and denturists procedures are calculated as follows: i) The total units of each procedure code paid in a prior period is multiplied by the RVU to equal the RVD for each procedure code. Typically, the prior period used is the prior state fiscal year. ii) The sum of all RVDs calculated 2. c. ( 1) ( b) ( 10 equals the total units of dental. service. iii) The Montana Legislature' s appropriation for dental service during the appropriation period is divided by the total units of dental service calculated in 2. c. ( 1) ( b) ( ii) . The resulting dollar value is equal to one unit of dental value and is the dental conversion factor. TN: 13- 019 Approved Date: Effective Date: 0- 7/ 01/ 2013 Supersedes TN: 11- 020

Page 2 of 2 Attachment 4 . 19B Methods and Standards for Establishing Payment Rates Service 10 Dental Services MONTANA iv) The R.VU for each dental procedure is multiplied by the dental conversion factor calculated in 2. c. ( 1.) ( b) ( iii) to calculate the Medicaid reimbursement for the procedure. When this calculation is made for all covered procedures the Montana Medicaid Dental, Dental Hygienist, and Denturist Fee Schedules are generated. v) A policy adjuster may be applied to some fees calculated in 2. c. ; 1) ( b) ( iv) for certain categories of services or to the conversion factor to increase or decrease the fees paid by Medicaid. 2) Where a fee cannot be set using this methodology, the reimbursement is determined using the " by report" methodology. The " by report' reimbursement is paid at 85% of the provider' s usual and customary charge. The ` By report' methodology will end by 6/ 30/ 14 . 3) Unless otherwise specified i.n the plan, the same published methodology is used to reimburse governmental providers and non- governmental providers. 4) The agency' s rates were set as of" the date on the Attachment 4 . 19B Introduction Page and are published at www. mtmedicaid. orq TN: 13- 019 Approved Date. SEP Z3 201 f'ect i ve Date: 01/ 01/ 2013 Supersedes TN. 11- 020

Page 1 of 2 Attachment 4. 19 B Methods and Standards For establishing Payment rates, Service 6 ( d) , Other Practitioner' s, Denturist Services Montana I. Reimbursement for Denturist Services shall be the lowest of the following: A. The provider' s usual and customary charge for the service; B. The Department' s fee schedule for denture services. II. The Department' s fee schedule is calculated as follows: A. Denture procedures are identified through the following process: 1. Procedures identified through ADA/ CDT coding manual; or 2. Denture procedures identified by the Department not identified in the current ADA/ CDT. B. Definitions: Relative Value Unit ( RVU) The unit value assigned to a specific procedure code published in c. ( 1) . Relative Value for Dentists( RVD) : a value given to each procedure code outlined in 2. c. ( 1) ( b) ( i) . C. Reimbursement rates are set by one of the following methods: 1) For procedures listed in the " Relative Values for Dentists" published biennially by Relative Value Studies, Incorporated, reimbursement rates shall be determined using the following methodology: a) The fee for a covered service shall be the amount determined by multiplying the ( RVU) by the conversion factor specified in 2. c. ( 1) ( b) ( iii) . b) The conversion factor and provider fees for dentists, dental hygienists, and denturists procedures are calculated as follows: i) The total units of each procedure code paid in a prior period is multiplied by the RVU to equal the RVD for each procedure code. Typically, the prior period used is the prior state fiscal year. 013 TN: 13- 019 Approved: SEP 2 3 2_ Effective: 07/ 01/ 2013 Supersedes TN: 11- 021

Page 2 of 2 Attachment 4. 19 B Methods and Standards For establishing Payment rates, Service 6 ( d) , Other Practitioner' s, Denturist Services ii) The sum of all RVDs calculated in 2. c. ( 1) ( b) ( i) equals the total units of dental. service. iii) The Montana Legislature' s appropriation for dental service during the appropriation period is divided by the total units of dental service calculated in 2. c. ( 1) ( b) ( ii) . The resulting dollar value is equal to one unit of dental value and is the dental conversion factor. iv) The RVU for each dental procedure is multiplied by the dental conversion factor calculated in 2. c. ( 1) ( b) ( iii) to calculate the Medicaid reimbursement for the procedure. When this calculation is made for all covered procedures the Montana Medicaid Dental, Dental Hygienist, and Denturist Fee Schedules are generated. v) A policy adjuster may be applied to some fees calculated in 2. c. ( 1) ( b) ( iv) for certain categories of services or to the conversion factor to increase or decrease the fees paid by Medicaid. 2) Where a fee cannot be set using this methodology, the reimbursement is determined using the " by report" methodology. The " by report' reimbursement is paid at 85% of the provider' s usual and customary charge. The ' By report' methodology will end by 6/ 30/ 14 . 3) Unless otherwise specified in the plan, the same published methodology is used to reimburse governmental providers and non- governmental providers. 4) The agency' s rates were set as of the date on the Attachment 4. 19B Introduction Page and are published at www. mtmedicaid. orq. TN: 13- 019 Approved:_ SEP 2 Effective: 07/ 01/ 2013 Supersedes TN: 11- 021

Page ( 1) of 2 Attachment 4 . 19 B Methods and Standards For establishing Payment rates, Service 6 ( d) , Other Practitioner' s, Dental Hygienist Services MONTANA 1. Reimbursement for Dental Hygienist Services provided when a Dental Hygienist has a limited access permit to practice under public health supervision" shall be the lowest of the following: a. The provider' s usual and customary charge for the service; b. The Department' s fee schedule for dental services. 2. The Department' s fee schedule is calculated as follows: a. Dental Hygienist preventative procedures are identified through the following process: 1. Procedures identified through ADA/ CDT coding manual. b. Definitions: Relative Value Unit ( RVU) The unit value assigned to a specific procedure code published in c. ( l) . Relative Value for Dentists( RVD) : a value given to each procedure code outlined in 2. c. ( 1) ( b) ( i) . C. Reimbursement rates are set by one of the following methods: 1) For procedures listed in the " Relative Values for Dentists" published biennially by Relative Value Studies, Incorporated, reimbursement rates shall be determined using the following methodology: a) The fee for a covered service shall be the amount determined by multiplying the ( RVU) by the conversion factor specified in 2. c. ( 1) ( b) ( iii) . b) The conversion factor and provider fees for dentists, dental hygienists, and denturists procedures are calculated as follows: TN: 13_ 019 Approved: SEP 2 3 2013 Effective: 07/ 01/ 2013 Supersedes TN: 11- 023

Page ( 2) of 2 Attachment 4. 19 B Methods and Standards For establishing Payment rates, Service 6 ( d) , Gather Practitioner' s, Dental Hygienist Services i) The total units of each procedure code paid in a prior period is multiplied by the RVU to equal the RVD for each procedure code. Typically, the prior period used is the prior state fiscal year. ii) The sum of all RVDs calculated in 2. c. ( 1) ( b) ( i) equals the total units of dental service. iii) The Montana Legislature' s appropriation for dental service during the appropriation period is divided by the total units of dental service calculated in 2. c. ( 1) ( b) ( ii) . The resulting dollar value is equal to one unit of dental value and is the dental conversion factor. iv) The RVU for each dental procedure is multiplied by the dental conversion factor calculated in 2. c. ( 1 ) ( b) ( iii) to calculate the Medicaid reimbursement for the procedure. When this calculation is made for all covered procedures the Montana Medicaid Dental, Dental Hygienist, and Denturist Fee Schedules are generated. v) A policy adjuster may be applied to some fees calculated in 2. c. ( 1) ( b) ( iv) for certain categories of services or to the conversion factor to increase or decrease the fees paid by Medicaid. 2. Where a fee cannot be set using this methodology, the reimbursement is determined using the " by report" methodology. The " by report' reimbursement is paid at 85% of the provider' s usual and customary charge. The ' By report' methodology will end by 6/ 30/ 14 . 3. The agency' s rates were set as of the date on the Attachment 4. 19B Introduction Page and are published on the agency' s website www. mtmedicaid. org. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private providers. TN: 13- 019 Approved: SEPv23 2G I3 Effective: 07/ 01/ 2013 Supersedes TN: 11- 023

Page 1 of 2 Attachment 4 . 19 B Methods and Standards For establishing Payment rates, Service 12. b, Denture Services Montana 1. Reimbursement for Denture Services shall be the lowest of the following: a. The provider' s usual and customary charge for the service; or b. The Department' s Fee schedule for denture services. 2. The Department' s fee schedule is calculated as follows: a. Denture procedures are identified through the following process: 1. Procedures identified through ADA/ CDT coding manual; or 2. Denture procedures identified by the Department not identi.fi.ed in the current ADA/ CDT. b. Definitions: Relative Value Unit ( RVU) The unit value assigned to a specific procedure code published in c. ( 1) . Relative Value for Dentists (RVD) : a value given to each procedure code outlined in 2. c. ( 1) ( b) ( i) . C. Reimbursement rates are set by one of the following methods: 1) For procedures listed in the " Relative Values for Dentists" published biennially by Relative Value Studies, Incorporated, reimbursement rates shall be determined using the following methodology: a) The fee for a covered service shall be the amount determined by multiplying the ( RVU) by the conversion Factor specified in 2. c. ( 1) ( b) ( iii) . b) The conversion factor and provider fees for dentists, dental hygienists, and denturi.sts procedures are calculated as follows: i) The total units of each procedure code paid in a prior period is multiplied by the RVU to equal the RVD for each procedure code. Typically, the prior period used is the prior state fiscal year. TN: 13- 019 Approved: $ Effective: 07/ 01/ 2013 FP.`. 21113 Supersedes TN: 11- 022

Page 1 of 2 Attachment 4 . 19 B Methods and Standards For establishing Payment rates, Service 12. b, Denture Services Montana 1. Reimbursement for Denture Services shall be the lowest of the following: a. The provider' s usual and customary charge for the service; or b. The Department' s Fee schedule for denture services. 2. The Department' s fee schedule is calculated as follows: a. Denture procedures are identified through the following process: 1. Procedures identified through ADA/ CDT coding manual; or 2. Denture procedures identified by the Department not identi.fi.ed in the current ADA/ CDT. b. Definitions: Relative Value Unit ( RVU) The unit value assigned to a specific procedure code published in c. ( 1) . Relative Value for Dentists (RVD) : a value given to each procedure code outlined in 2. c. ( 1) ( b) ( i) . C. Reimbursement rates are set by one of the following methods: 1) For procedures listed in the " Relative Values for Dentists" published biennially by Relative Value Studies, Incorporated, reimbursement rates shall be determined using the following methodology: a) The fee for a covered service shall be the amount determined by multiplying the ( RVU) by the conversion Factor specified in 2. c. ( 1) ( b) ( iii) . b) The conversion factor and provider fees for dentists, dental hygienists, and denturi.sts procedures are calculated as follows: i) The total units of each procedure code paid in a prior period is multiplied by the RVU to equal the RVD for each procedure code. Typically, the prior period used is the prior state fiscal year. TN: 13- 019 Approved: $ Effective: 07/ 01/ 2013 FP.`. 21113 Supersedes TN: 11- 022

Page 2 of 2 Attachment 4. 19 B Methods and Standards For establishing Payment rates, Service 12. b, ii) The sum of all RVDs calculated in 2. c. ( 1) ( b) ( i) equals the total units of dental service. iii) The Montana Legislature' s appropriation for dental service during the appropriation period is divided by the total units of dental service calculates. in 2. c. ( 1) ( b) ( ii) . The resulting dollar value is equal to one unit of dental value and is the dental conversion factor. iv) The RVU for each dental procedure is multiplied by the dental conversion ` actor calculated in 2. c. ( 1) ( b) ( iii) to calculate the Medicaid reimbursement for the procedure. When this calculation is made for all covered procedures the Montana Medicaid Dental, Dental Hygienist, and Dentur.ist Fee Schedules are generated. v) A policy adjuster may be applied to some fees calculated in 2. c. ( 1) ( b) ( iv) for certain categories of services or to the conversion factor to increase or decrease the fees paid by Medicaid. 2) Where a fee cannot be set using this methodology, the reimbursement is determined using the " by report" methodology. The " by report' re.i.c: ibursement is paid at 85% of the provider' s usual and customary charge. The ' By report' methodology will end by 6/ 30/ 14. 3) Unless otherwise specified in the plan, the same published methodology is used to reimburse governmental providers and non- governmental providers. 4) The agency' s rates were set as of the date on the Attachment 4. 19E Introduction Page and are published at www. mtmedicaid. org. TN; 13- 019 Approved. SEP 2' 3 2013 Effective; 07/ 01/ 2013 Supersedes TN: 1_ 1- 022

Page 2 of 2 Attachment 4. 19 B Methods and Standards For establishing Payment rates, Service 12. b, ii) The sum of all RVDs calculated in 2. c. ( 1) ( b) ( i) equals the total units of dental service. iii) The Montana Legislature' s appropriation for dental service during the appropriation period is divided by the total units of dental service calculates. in 2. c. ( 1) ( b) ( ii) . The resulting dollar value is equal to one unit of dental value and is the dental conversion factor. iv) The RVU for each dental procedure is multiplied by the dental conversion ` actor calculated in 2. c. ( 1) ( b) ( iii) to calculate the Medicaid reimbursement for the procedure. When this calculation is made for all covered procedures the Montana Medicaid Dental, Dental Hygienist, and Dentur.ist Fee Schedules are generated. v) A policy adjuster may be applied to some fees calculated in 2. c. ( 1) ( b) ( iv) for certain categories of services or to the conversion factor to increase or decrease the fees paid by Medicaid. 2) Where a fee cannot be set using this methodology, the reimbursement is determined using the " by report" methodology. The " by report' re.i.c: ibursement is paid at 85% of the provider' s usual and customary charge. The ' By report' methodology will end by 6/ 30/ 14. 3) Unless otherwise specified in the plan, the same published methodology is used to reimburse governmental providers and non- governmental providers. 4) The agency' s rates were set as of the date on the Attachment 4. 19E Introduction Page and are published at www. mtmedicaid. org. TN; 13- 019 Approved. SEP 2' 3 2013 Effective; 07/ 01/ 2013 Supersedes TN: 1_ 1- 022

EPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED JEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13- 019 Montana FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT( MEDICAID) TO: REGIONAL ADMINISTRATOR 1 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 07/01/ 2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT( Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 1 7. FEDERAL BUDGET IMPACT: 1902(a)( 30)(A) a. FFY 13$ 75, 181 b. FFY 14$ 302,229 c. FFY 15$ 302,229 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable): 4. 19B Methods& Standards for Establishing Payment Rates for Service 10 Dental Services, Denturist Service 6(d), Denture Service 4.19B Methods& Standards for Establishing Payment Rates 12( b), Dental Hygienist Service 6(d). for Service 10 Dental Services, Denturist Service 6(d), Denture Service 12(b), Dental Hygienist Service 6(d). 10. SUBJECT OF AMENDMENT: The purpose of this amendment is to change the date the agency' s rates were set. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL E 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: C Montana Dept of Public Health and Human Services 13. TYPED NAME: Mary E. lton Mary E. Dalton, State Medicaid Director Attn: Jo Thompson 14. TITLE: State Medicaid Director PO Box 4210 i Helena MT 59604 15. DATE SUBMITTED: 7'1 / N OF `IC USZ,,. ONLY 48. DATE APPROVE w r y{M/ Ova- I!. CC) P cy 191lCI"k Ia€ 3 yt„ 3 I/}} R i aq ' 8 iI.MR A q f £ r -• ,, i A' S. TAT 1l TT/' RJ A I an ins WIN

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

September 23, 2013

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-13-023

Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-023. This SPA increases rates 2% and changes the date the agency's rates were set for Chiropractic Services.

Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Anna Whiting Sorrell Duane Preshinger Jo Thompson

Page I of 2 Attachment 4. 198 Methods and Standards for Establishing Payment Rates, Service 6( d) Chiropractic Services MONTANA T Reimbursement for Chiropractic Services under the EPSDT ( under age 21) Program shall be the lower of: A. The provider' s usual and customary charge for the service; B. Reimbursement provided in accordance with the methodology described in II. The Department' s fee schedule for Chiropractic Services is determined: A. In accordance with the Resource Base Relative Value Scale RBRVS) methodology, by multiplying Medicare' s Relative Value Units ( RVU) , which is numeric, by the Montana Medicaid specific conversion factor, which is a dollar amount, to equal a fee. Specific to Montana Medicaid, there is an ability to multiply the fee times a policy adviser ( either plus or minus) to affect the fee. B. " Resource based relative value scale ( RBRVS) " means the most current version of the Medicare resource based relative value scale contained in the physicians' Medicare Physician Fee Schedule adopted by the Centers for Medicare and Medicaid Services ( CMS) . C. " Relative value unit (RVU)" means a numerical value assigned in the resources based relative value scale to each procedure code used to bill for services provided by a health care provider. The relative value unit assigned to a particular code expresses the relative effort and expense expended by a provider in providing one service as compared with another service. D. The RVU' s are adopted from the RBRVS. For the services for which the RBRVS does not specify RVU' s, the department sets those RVU' s as follows: TN: 13- 023 Approved: SEP 2',3 2013 Effective: 07/ 010201.3 Supersedes TN: 1. 2- 022

Page 2 of 2 Attachment 4. 198 Methods and Standards for Establishing Payment Rates, Service 6( d) Chiropractic Services MONTANA The RVUs for a Medicaid covered service are calculated as f o l,,,, ows: i. If Medicare sets RVU' s, the Medicare RVU' s are applicable; ii. If Medicare does not set RVU' s but Medicaid sets RVUs, the Medicaid RVUs are set in the followi.r: g manner: A) convert the existing dollar value of a fee to an RVU value; B) evaluate the RVU of similar services and adding an RVU value; or convert the average by .report dollar value of a fee to an RVU value. C) convert the average by report dollar value of a fee to an RVU value. E. If there is riot a Medicare RVU or Medicaid history data, reimbursement will be ` by report' . `By report' means paying a percentage of billed charges. The percentage is derived by dividing the previous state fiscal year' s total.. Medicaid reimbursement for services included in the RBRVS by the previous state fiscal year' s total Medicaid billings. The by report' methodology will end by 6/ 30/ 1. 4. F. The agency' s rates were set as of the date on the Attachment 4. 19E Introduction Page and are published on the agency' s website www. mtmedicai.d. org. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private providers. 3 Zp13 TN: 13- 023 Approved: SEP Effective: 07/ 01./ 2013 Supersedes TN: 12- 022

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13- 023 Montana FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT( MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 07/01/ 2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT( Separate Transmittal for each amendment 6.FEDERAL STATUTEIREGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 1902(a)( 30)( A) a. FFY 13 $ 84 b. FFY 14 $ 336 c. FFY 15 $ 336 i 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable): Attachment 4. 1911 Methods& Standards for Establishing Payment Attachment 4.19B Methods& Standards for Establishing Rates for Service 6(d) Chiropractic Services. Payment Rates for Service 6(d) Chiropractic Services. i 10. SUBJECT OF AMENDMENT: The purpose of this amendment is to increase rates 2% and to update the date the agency' s rates were set. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Montana Dept of Public Health and Human Services 13. TYPED NAME: Mary E. D n Mary E. Dalton, State Medicaid Director Attn: Jo Thompson 14. TITLE: State Medicaid Director PO Box 4210 1 Helena MT 59604 15. DATE SUBMITTED: DATE AtBR JL pg 0" ifrUFI `CIAL,;' 11 r,.; 4FFw" FORM NCFA- 17Q( tl7_Q'M

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

September 23, 2013

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-13-026

Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-026. This SPA increases rates 2% and changes the date the agency's rates were set for Hearing Aid Services.

Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Anna Whiting Sorrell Duane Preshinger Jo Thompson

Page 1 of 1 Attachment 4 . 19B Methods & Siandards For Establishing Payment Rates, Service 12. c, HEARING AIDS MONTANA I. Reimbursement for Hearing Aid Services ( excluding hearing aids) shall be the lower of the following: a. The provider' s* usual and customary charge for the service, or b. The Department' s fee schedule II. Reimbursement for Hearing Aid( s) shall be: a. The invoice cost for hearing aids from the manufacturer not to exceed the established rate on the fee schedule. b. The invoice cost from the manufacturer for hearing aid repairs, or III . The Department' s fee schedule is determined by: a. Establishing a fee for each new service which has been billed at least 50 times by all providers in the aggregate during the previous 12 month period. The Department shall set each fee at 90 of the average charge billed by all providers in the aggregate. The ` by report' methodology will end by 6/ 30/ 14 . IV. All private and governmental providers are reimbursed according to the same published fee schedule. The agency' s rates were set as of the date on the Attachment 4 . 19B Introduction Page and are published at .r,r.;a. r ` r.t: ci •,j J. cr-;. TN 13- 026 Approved SEP 2, 3 2013 Effective 07/ 01/ 2013 Supersedes TN 12- 025

DEPAR'T' MENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION _ OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13- 026 Montana FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: Title XIX of the Social Security Act( Medicaid) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION July 01, 2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT( Separate Transmittatfor each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: T 7 FEDERAL BUDGET IMPACT: Section 1902( a)( 30XA) a. FFY 2013 555 b. FFY 2014 2,230 c. FFY 2015 2,230 i 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Page( s) 1 of 1 OR ATTACHMENT( IfApplicable): Attachment 4. 19B Page( s) 1 of 1 Methods& Standards for Establishing Payment Rates Attachment 4. 19B Service 12.c Hearing Aids Methods& Standards for Establishing Payment Rates Service 12.c Hearing Aids 10. SUBJECT OF AMENDMENT: Amend Services 12.c Hearing Aid to increase the rate 2% and update the date of the fee schedule. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: SINGLE COMMENTS OF GOVERNOR' S OFFICE ENCLOSED AGENCY DIRECTOR REVIEW NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: f Montana Dept. of Public Health and Human Services 13. TYPED NAME: Ma . Dalton Mary E. Dalton State Medicaid Director 14. TITLE: State Medicaid Director Attn: Jo Thompson PO Box 4210 15. DATE SUBMITTED: Helena, MT 59604 IMASM01ALOMC11VSlB OWN 110ANO - 0 a ,:.: ia•a a;=": i x < t is.. r XStSL: IMF 21. WfV i a y o 4 " a '$' " y, a .. •, 3 zssF r'„ : p; s, ,` ps°,' r-. . t •..'? 8 °.+ t,L,: y "` 3' " V? S: a I'°:}° Y, '' . >` 8..., = T • E.'" n F„ a• x .,.. sr aro. is°. y" *` e'* R Y 7s's•kr' II ' i.; ::.. s° a , y:" y', - F<. k+c<d 3`". a `=" e E a` " re i' yT3' . dtA• 15: uv`-<'.+. ty: F a:,.•; ms`y t•:* .' 1e s " iA' t: h=, . T`,. t a x<k• zr3z. ' a' Ves§ a„' gym. . e, . a. r•r'> e: 3.Y£:' k:' F.d•$' H' s', bSF'J• l'+"x>35s'. E¢: fie n' i s..% E 3,.§.' r f.`=F'." M x,.. sc=.::' .,. 4 3 . iY° y' 2^ s) S<8 A x%< Fa u, " 2.` d` 9 i i € - e r." H , 4s# ; ^' fl' F J d ;';€.,•< a.!'^ '"< p', A FnRM T4 FA_179( 07-Wl

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

September 23, 2013

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-13-028

Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-028. This SPA increases rates 2% and changes the date the agency's rates were set for Home Health Services.

Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Anna Whiting Sorrell Duane Preshinger Jo Thompson

Page 1 of 2 Supplement to Attachment 3. 1A Services 7a, b, c & d Home Health Services MONTANA The following limits apply to Home Health Services: 1. A person receiving personal care attendant services may not receive concurrent home health aide services. 2. Home health services do not include audiology services. 3. Home health services may be provided by providers out of state only when the services are authorized by the Department. 4. Services considered experimental are not a benefit of the Montana Medicaid Program. Experimental services include: a. All procedures and items, including prescribed drugs, considered experimental by the U. S. Department of Health and Human Services or any other appropriate federal agency. b. All procedures and items, including prescribed drugs, provided as part of a control study, approved by the Department of Health and Human Services or any other appropriate federal agency to demonstrate whether the item, prescribed drug or procedure is safe and effective in curing/ preventing, correcting or alleviating the effects of certain medical conditions. C. All procedures and items, including prescribed drugs, which may be subject to question but are not covered in # 1 and # 2 above, will be evaluated by the Department' s designated medical review organization. 5. Limits recipient to one ( 1) Wheelchair every five ( 5) years: sooner based on medical necessity review performed by the Department, 6. Limits recipients using diapers, to nearest package size over 180 diapers, per month. 7. Purchases or rental of medical equipment exceeding $ 1, 000 must be prior authorized by the Department. 8. Nursing services provided by a home health agency or by a registered nurse when no home health agency exists in the area may be used by home infusion therapy agencies for the administration of home infusion therapy. 9. The durable medical equipment and supplies required for home infusion therapies will be provided by home infusion therapy agencies licensed by the Department of Health and Human Services. TN # 13- 028 Approved Effective / 7/ 1/ 13 Supersedes TN # 96- 13 SEP 2 3 2013

Page 1 of 2 Supplement to Attachment 3. 1B Services 7a, b, c & d Home Health Services MONTANA The following limits apply to Home Health Services: 1. A person receiving personal care attendant services may not receive concurrent home health aide services. 2. Home health services do not include audiology services, 3. Home health services may be provided by providers out of state only when the services are authorized by the Department. A. Services considered experimental are not a benefit of the Montana Medicaid Program. Experimental services include: a. All procedures and items, including prescribed drugs, considered experimental by the U. S. Department of Health and Human Services or any other appropriate federal agency. b. All procedures and items, including prescribed drugs, provided as part of a control study, approved by the Department of Health and Human Services or any other appropriate federal agency to demonstrate whether the item, prescribed drug or procedure is safe and effective in curing/ preventing, correcting or alleviating the effects of certain medical conditions. C. All procedures and items, including prescribed drugs, which may be subject to question but are not covered in # 1 and # 2 above, will be evaluated by the Department' s designated medical review organization. 5. Limits recipient to one ( 1) Wheelchair every five ( 5) years: sooner based on medical. necessity review performed by the Department, 6. Limits recipients using diapers, to nearest package size over 180 diapers, per month. 7. Purchases or rental of medical equipment exceeding $ 1, 000 must be prior authorized by the Department. S. Nursing services provided by a home health agency or by a registered nurse when no home health agency exists in the area may be used by home infusion therapy agencies for the administration of home infusion therapy. 9. The durable medical equipment and supplies required for home infusion therapies will be provided by home infusion therapy agencies licensed by the Department of Health and Human Services. TN # 13- 028 Approved Effective / 7/ 1/ 13 Supersedes TN # 96- 13 SEP 2, 3 20*

Page 1 of 1 Attachment 4. 19B Methods & Standards For establishing Payment rates, Services 7a and b Home Health Services MONTANA 1. Reimbursement for Home Health Skilled Nursing Services and Horne Health Aide Services shall be the lower of: A. The provider' s actual ( submitted) charge for the service; or B. The rate posted on the Department' s fee schedule. 2. A unit of service is an in- person visit by the nurse or aide to provide care to the Medicaid individual. 3. The agency' s rates were set as of the date on the Attachment 9 . 19E Introduction Page and are published at www. mtmedicaid. org. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private providers. TN# 13- 028 Approved SEp 23 2013 Effective: 7/ 1/ 13 Supersedes TN # 97- 017

Page 1 of 1 Attachment 4. 19E Methods & Standards For establishing Payment rates, Services 7d Home Health Services MONTANA 1. Reimbursement for Home Health Physical Therapy, Speech Therapy and Occupational Therapy shall be the lower of the following: A. The provider' s actual ( submitted) charge for the service; or B. The Department' s fee schedule. 2. A unit of service is an in- person visit by the therapist to provide care to the Medicaid individual. 3. The agency' s rates were set as of the date on the Attachment 4. 198 Introduction Page and are published at www. mtmedicaid. org. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private providers. TN# 13- 028 Approved 201, Effective: 7! 1! 13 Supersedes TN # 97- 017 SEQ 2 3

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 093" 193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13- 028 i Montana FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: Tide XIX of the Social Security Act( Medicaid) REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 7111,2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES __... ..........__... ........ ....... 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT( Separate Transmittal reachamendment) Separate-----------.............. f2.......... ..................................... 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Section 1902( a)( 30)( A) a. FFY 13:$ 102,830 b. FFY 14:$ 418, 170 c. FFY 15:$ 436,699 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: f 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable): Attachment 3. 1 A, Home Health Services 7a, b, c& d Attachment 3. 1 B, Home Health Services 7a, b, c& d Attachment 3. 1 A, Home Health Services 7a, b, c& d Attachment 4. 19B, Home Health Services 7a and 7b Attachment 3. 1 B, Home Health Services 7a, b, c& d Attachment 4. 19B, Home Health Services 7d Attachment 4. 19B, Home Health Services 7a and 7b Attachment 4. 19B, Home Health Services 7d 10. SUBJECT OF AMENDMENT: Amend Home Health Services to include an approximate 2% rate increase and to incorporate the fee schedule. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED Single Agency Director Review. NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURJF OF STATE AGENCY OFF' CIAL: 16* RETURN TO: MLIA I I" Montana Dept. of Public Health and Human Services AM Mary E. Dalton 13. TYPED tonr State Medicaid Director 14. TITLE: State Medicaid Director Attn: Jo Thompson PO Box 4210 15. DATE SUBMITTED: ---- qT, I, 3 1 Helena, MT 59604 11 FOR REGIONAL OFFICE USE I __ l _ 17. DATE RECEIVED: 7 113 18. DATE APPROVED: PLAN APPROVED ONE COPY ACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 2 IGN I POFF10A1.. ......................... 21. TYPED NAME: 23. REMARKS: FORM HCFA- 179( 07-92)

Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: MT- 13- 029 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages TN: MT- 13- 029 Approval Date: 01/ 29/ 14 Effective Date: 07/ 01/ 13

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services mom 1600 Broadway, Suite 700 Denver, CO 80202-4967 M 's r", O, 1F t3bC..", h:t,:L4 dt",laSC,:-dill f4 d. E4 Region VIII January 29, 2014 Mary Dalton, Medicaid & Health Services Manager Montana Department of Health& Human Services 1400 Broadway PO Box 202951 Helena, MT 59620 Re: SPA MT- 13- 029 Dear Ms. Dalton: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number MT- 13- 029. This SPA amends Physician Services to update fees by 5. 7% and the date of the fee schedule. Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the summary page and the amended plan page( s). If you have any questions regarding this SPA please contact Cindy Smith at 303- 844-7041. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health Operations Cc: Richard Opper, Department Director Duane Preshinger Jo Thompson

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13- 029 Montana FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: Title XIX of the 1--"--"'----'- Social Security Act( Medicaid) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION July 1, 2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT' TO BE CONSIDERED AS NEW PLAN X AMENDMENT COMPI-FTEBLOCKS 6 THRU 10 IF THIS IS AN AMENDMENTS Lf paraleTransmiqq or each amendment) I _ FEDERAL S'— TATUTE/'R' EG--U--L-AT-ION CITATION: 7. FEDERAL BUDGET IMPACT: Section j 902( a),( 3 a. FFY 2013 488, 030( 3 months) b. FFY 2014 1, 979,498( 12 months) c. FFY 2015 1, 546,223( 9 months) 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable): Attachment 4. 19B, Pages 1 and 2 of 5, Service 5a Physician Services rjeinena to Anachl-muL 3,-,1 A' 3, B, Ser, ice 5a 11'hysician Services Attachment 4. 19B, Pages I and 2 of 5, Service 5a Physician Attach Q 11- sat tic 1) serv, Services pppleawm to Attachnient 3, 1 A,.( 3..., Sei'v' ce 5a 111i swian Sep caws AlItItla.c1liln,'nij 4, 1 QB. Senice12 a, Ow afien , Drw S,, rvices 10. SUBJECT OF AMENDMENT: Amend Service 5a Physician Services to update fees by 5. 7% and the date of the fee schedule. Notice of Public Hearing on Proposed Amendment, MAR Notice No. 37- 636. T rel catc pbysician admunqer d f oq Services, Set vict 5a w Outp;V wnl QT w Q viQe 12a, es, Sei Ii. GOVERNOR' S REVIEW( Check One). GOVERNOR' S OFFICE REPORTED NO COMMENT XOTHER, AS SPECIFIED: SINGLE COMMENTS OF GOVERNOR' S OFFICE ENCLOSED AGENCY DIRECTOR REVIEW NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE rw ....... 16. RETURN TO: Montana Dept. of Public Health and Human Services 13. TYPED NAME: Mary T E. Dilton Mary E. Dalton State Medicaid Director 14. TITLE: State Medicaid Director Attn: Jo Thompson PO Box 4210 Helena, MIT 59604 15. DATE SUBMITTED: 6/27/13 FOR REGIONAL OFFICE USE ONLY 17 DATE RECEIVED June 11 ne 27, 2013. - 18, 15XiE APPROVED January- 11 2"9, 2014 1 " 1 .............................- PLAN APPROVED ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20, SIGNATURE OF REGIONAL OFFICIAL: s/ 21. TYPED NAME: 22, TITLE: Richard C. Allen ARA, DMCHO 23. REMARKS; FORM HCFA- 179( 07-92)

Page 1 of 1 Supplement to Attachment 3. 1B a Service 5a Physicians' Services MONTANA The following limitations apply to Physicians' Services: 1. Physicians' Services for conditions or ailments that are generally considered cosmetic in nature are not a benefit of the Medicaid Program except in such cases where it can be demonstrated that the physical well- being and psycho- social well- being of the recipient are severely affected in a detrimental manner. The determination of whether a service is cosmetic will be made by the Department or its designated review organization. 2. Services considered experimental are not a benefit of the Montana Medicaid Program. Experimental services include: a. All procedures and items, including prescribed drugs, considered experimental by the U. S. Department of Health and Human Services or any other appropriate federal agency. b. All procedures and items, including prescribed drugs, provided as part of a control study, approved by the Department of Health and Human Services, or any other appropriate federal agency to demonstrate whether the item, prescribed drug or procedure is safe and effective in curing/ preventing, correcting or alleviating the effects of certain medical conditions. C. All procedures and items, including prescribed drugs, which may be subject to question but are not covered in #1 and # 2 above, will be evaluated by the Department' s designated medical review organization. TN 13- 029 Approved Effective 7/ 1/ 2013 Supersedes TN # 10- 002

Page 1 of 1 Supplement to Attachment 3. 1A Service 5a Physicians' Services MONTANA The following limitations apply to Physicians' Services: 1. Physicians' Services for conditions or ailments that are generally considered cosmetic in nature are not a benefit of the Medicaid Program except in such cases where it can be demonstrated that the physical well- being and psycho- social well- being of the recipient are severely affected in a detrimental manner. The determination of whether a service is cosmetic will be made by the Department or its designated review organization. 2. Services considered experimental are not a benefit of the Montana Medicaid Program. Experimental services include: a. All procedures and items, including prescribed drugs, considered experimental by the U. S. Department of Health and Human Services or any other appropriate federal agency. b. All procedures and items, including prescribed drugs, provided as part of a control study, approved by the Department of Health and Human Services, or any other appropriate federal agency to demonstrate whether the item, prescribed drug or procedure is safe and effective in curing/ preventing, correcting or alleviating the effects of certain medical conditions. C. All procedures and items, including prescribed drugs, which may be subject to question but are not covered in #1 and # 2 above, will be evaluated by the Department' s designated medical review organization. TN 13- 029 Approved Effective 7/ 1/ 2013 Supersedes TN # 10- 002

Page 1 of 5 Attachment 4. 19B Methods and Standards for Establishing Payment Rates Service 5 ( a) Physicians' Services MONTANA I. Reimbursement for Physician Services shall be: A. The lower of: 1. The provider' s usual and customary charge for the service; or 2. Reimbursement provided in accordance with the methodology described In Number II. II. The Department' s fee schedule for Physician Services is determined: A. In accordance with the Resource Based Relative Value Scale RBRVS) methodology, by multiplying Medicare' s Relative Value Units ( RVU) , or Medicare' s base and time units for anesthesia services, which is numeric, by the Montana Medicaid specific conversion factor, which is a dollar amount, to equal. a fee. Specific to Montana Medicaid, there is an ability to multiply the fee times a policy adjuster ( either plus or minus) to affect the fee. B. RBRVS means the version of the Medicare resource based relative value scale contained in the Medicare Physician Fee Schedule MPFS) adopted by the Centers for Medicare and Medicaid Services CMS) . C. RVU means a numerical value assigned in the RBRVS to each procedure code used to bill for services provided by a health care provider. The RVU assigned to a particular code expresses the relative effort and expense expended by a provider in providing one service as compared with another service. TN 13- 029 Approved 01/ 29/14 Effective 7/ 1/ 2013 Supersedes TN 1. 2- 02.0

Page 2 of 5 Attachment 4. 19E Methods and Standards for Establishing Payment Rates Service 5 ( a) Physicians' Services MONTANA D. The RVUs are adopted from the RBRVS. 1. if Medicare sets RVUs, the Medicare RVUs are applicable; 2. If. Medicare does not set RVUs but Medicaid sets RVUs, the Medicaid RVUs are Set in the following manner: a) convert the existing dollar value of a fee _c an RVU value; b1% evaluate the RVU of similar services and assign an RVU value; or c) convert the average by report dollar value of a fee to an RVU value. E. If neither Medicare nor Medicaid sets RVUs, then reimbursement is ' by report' . ' By report' means paying a percentage of billed charges. The percentage is derived by dividing the previous state fiscal year' s total Medicaid reimbursement for services included in the RBRVS by the previous state fiscal year' s total Medicaid billings. The " by report" methodology will end by 6/ 30/ 14. Except as otherwise nnted in the plan, state- developed fee schedule rates are the same for both governmental and private providers of physician services. The agency' s fee schedule rate was set as of July 1, 2013 and is effective for services provided on or after that date. All rates are published at N 13- 029, Approved 01/ 29/14 Effective 7/ 1/ 2013 Supersedes TN 12- 020

Page 1 of 2 Attachment4.19B Methods and Standards For Establishing Payment Rates, Service 12 a, Outpatient Drug Services MONTANA Reimbursement for drugs shall not exceed the lowest of: 1. The Estimated Acquisition Cost( EAC) of the drug plus a dispensing fee, or; 2. Federal Upper Limit( FUL) of the drug plus a dispensing fee, or; 3. The State Maximum Allowable Cost( SMAC) of the drug, in the case of multi-source( generic), plus a dispensing fee, or, 4. The provider' s usual and customary charge of the drug to the general public. Exceotion The FUL limitation shall not apply in a case where a physician certifies in his/her own handwriting the specific brand is medically necessary for a particular recipient. An example of an acceptable certification is the handwritten notation" Brand Necessary" or" Brand Required" A check off box on a form or rubber stamp is not acceptable. Exceotion: For outpatient drugs provided to Medicaid recipients in state institutions, reimbursement will conform to the state contract for pharmacy services; or for institutions not participating in the state contract for pharmacy services, reimbursement will be the actual cost of the drug and dispensing fee. In either case, reimbursement will not exceed, in the aggregate, the EAC or FUL or the SMAC plus the dispensing fee. The EAC is established by the state agency using the Federal definition of EAC as a guideline: that is," Estimated Acquisition Cost" means the state agency's best estimate of what price providers generally pay for a particular drug. The EAC, which includes single source, brand necessary and drugs other than multi-source, is established using the following methodology: Drugs paid by their Average Wholesale Price( AWP) will be paid at AWP less 15 percent or Wholesale Acquisition Cost( WAC) plus 2 percent. If the state agency determines that acquisition cost is lower than AWP less 15 percent or WAC plus 2 percent then the state agency may set an allowable acquisition cost based on data provided by the drug pricing file contractor. The SMAC for multiple-source drugs shall be equal to the state average acquisition cost per drug determined by direct pharmacy survey, wholesale survey and other relevant cost information. A variable dispensing fee will be established by the state agency. The dispensing fee is based on the pharmacy' s average cost of filling a prescription. The average cost of filling a prescription will be based on the direct and indirect costs that can be allocated to the cost of the prescription department and that of filling a prescription, as determined from the Montana dispensing fee questionnaire. A provider's failure to submit, upon request, the dispensing fee questionnaire property completed will result in the assignment of the minimum dispensing fee offered. A copy of the Montana dispensing fee questionnaire is available upon request from the department. TN 13- 029 Approved 01/ 29/14 Effective 07/ 01/ 2013 Supersedes 13- 010

Page 2 of 2 Attachment 4. 19B Methods and Standards For Establishing Payment Rates, Service 12 a., Outpatient Drug Services MONTANA Dispensing fees shall be established as follows: 1. The dispensing fees assigned shall range between i) a minimum of$ 2. 00 and a maximum of$ 4. 94 for brand name and nonpreferred generic drugs; and ii) a minimum of$ 2.00 and a maximum of$ 6.52 for preferred brand name and generic drugs and generic drugs not identified on the preferred list. 2. Out-of-state providers will be assigned a$ 3. 50 dispensing fee. 3. If the individual provider's usual and customary average dispensing fee for filling prescription is less than the foregoing method of determining the dispensing fee, then the lesser dispensing fee shall be applied in the computation of the payment to the pharmacy provider. In-state pharmacy providers that are new to the Montana Medicaid program will be assigned the maximum dispensing fee in( 1) until a dispensing fee questionnaire can be completed for six months of operation. At that time, a new dispensing fee will be assigned which will be the lower of the dispensing fee calculated for the pharmacy or the maximum allowed dispensing fee provided in( 1). Failure to comply with the six months dispensing fee questionnaire requirement will result in assignment of dispensing fee of$ 2.00. An additional dispensing fee of$ 0.75 will be paid for" unit dose" prescriptions. This" unit dose" dispensing fee will offset the additional cost of packaging supplies and materials which are directly related to filling" unit dose" prescriptions by the individual pharmacy and is in addition to the regular dispensing fee allowed. Only one unit dose dispensing fee will be allowed each month for each prescribed medication. A dispensing fee will not be paid for a unit dose prescription packaged by the drug manufacturer. The pharmacist vaccine administration fee shall be$ 21. 32 for the first vaccine and$ 13.38 for each additional vaccine administered. This fee will be provided in lieu of the dispensing fee for any covered vaccine. An additional compounding fee based on level of effort will be paid for compounded prescriptions. Montana Medicaid shall reimburse pharmacies for compounding drugs only if the client's drug therapy needs cannot be met by commercially available dosage strengths and/or forms of the therapy. Reimbursement for each drug component shall be determined in accordance with" lower or pricing methodology. The compounding fee for each compounded drug shall be based on the level of effort required by the pharmacist. The levels of effort compounding fees payable are level 1:$ 12. 50, level 2:$ 17 50, and level 3:$ 22.50. Physician Administered Drugs The Department requires that National Drug Codes( NDC) must be submitted for all physician administered drugs. Montana Medicaid will cover only those physician administered drugs manufactured by companies that have a signed rebate agreement with CMS. Reimbursement for physician- administered drugs is made according to the department's fee schedule or the provider's usual and customary charge, whichever is lower. The physician administered drug fee schedule is updated effective the 15` day of each quarter as determined by: 1. The Medicare Average Sales Price( ASP) methodology( of ASP+6%) if there is an ASP fee; or 2. The estimated acquisition cost( EAC) as defined above; TN 13- 029 Approved 01/ 29/14 Effective 07/01/ 2013 Supersedes 13-010

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

September 23, 2013

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-13-030

Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-030. The purpose of this SPA is increase rates and change the date the Agency’s rates were set for Targeted Case Management for Youth with Severe Emotional Disturbance.

Please be informed that this State Plan Amendment is approved today with an effective date of July 1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Anna Whiting Sorrell Duane Preshinger Jo Thompson

Page 1 of 1 Attachment 4. 196 Methods & Standards for Establishing Payment Rates Service 19 D. Targeted Case Management Services for Youth with Serious Emotional Disturbance( SED) Targeted Case Management( TCM) for youth with Serious Emotional Disturbance( SED) services are provided by a licensed mental health center with a license endorsement permitting the mental health center to provide case management services. TCM services for youth with SED are reimbursed on a fee per unit of service basis. A unit of service is a period of 15 minutes. Reimbursement for TCM services for youth with serious emotional disturbance is the lower of: the providers' actual charge for the service or the Department' s fee. Unless otherwise noted in the State Plan, fees are the same for both governmental and private providers. The Department' s rates were set as of the date specified on the Attachment 4. 1913 Introduction Page and are published at http•//www dphhs mt.gov/ mentalhealth/ children/feeschedule. pdf. TN 13- 030 Approved J Effective 7/ 1/ 13 Supersedes TN 11- 031

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938- 0193 AL STATE TRANSMITTAL AND NOTICE OF APPROVAL OF i. TRANSMITIALNUMBER: STATE PLAN MATERIAL 3- 030 7montana THE FOR: HEALTH CARE FINANCING ADMINISTRATION PROGRAM-IDENTIFICATION. TITLE XIX OF SOCIAL SECURITY ACT( MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 07101;'2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT qqr Transmittal for each amendmen!), Tt-D-E-R--A-- L--ST-AT-U--TE-/RE-G-U-L-AT-1-0--, N---- Cl-T-A--T-I-- O-,- N: 7. FhbkRAL BUDGET ACT: 1902( a)( 30)( A) a. FFY 13 $ 555, 151 b. FFY 14 $ 2,240,205 1 c. FFY 15 $ 1, 724,258 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable): 4. 19B Methods& Standards for Establishing Payment Rates, Service 4. 19B Methods& Standards for Establishing Payment Rates, 19D. Targeted Case Management Services for Youth with Serious Service 19D. Targeted Case Management Services for Youth with Emotional Disturbance( SED), Page I Serious Emotional Disturbance( SED), Pages 1- 3 10. SUBJECT OF AMENDMENT: The Targeted Case Management for SED amendment increases the rate by the amount appropriated by the 2013 Legislative Session and updates the date of the fee schedule on the Attachment 4. 19B Introduction Page. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Montana Dept of Public Health d Human Services J;. and E. Dalton, State Medicaid Director 13. TYPED NAME: MarJ- Dalton Attn: Jo Thompson 14. TITLE: State Medicaid Director PO Box 4210 Helena MT 59604 15. DATE SUBMITTEI)7 FOR REGIONAL OFFICE USE ONLY DATE RECEIVED- 1 18. DATE APPROVED- 7 113 rnll5ek elllbI13 1 113 11. 11111- 11- 11---------- PLAN APPROVED- ONE COPY CHED 19. EFFECTIVE DATE OF APP VKID-MATERIAL: 20. OFFICIAL:( 3 AL TYPED NAME: 22. REMARKS: FORM HCFA- 179( 07- 92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

September 23, 2013

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-13-032

Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-032. This SPA increases rates 2% and changes the date the agency's rates were set for Licensed Professional Counselor Services.

Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Anna Whiting Sorrell Duane Preshinger Jo Thompson

Page 1 of 2 Attachment 4 . 19E Methods & Standards For Establishing Payment Rates, Service 6. ( d) Licensed Professional Counselors' Services MONTANA I. Reimbursement for Licensed Professional Counselors' Services shall be: A. The lower of: 1. The provider' s* usual and customary charge for the service; or 2. The reimbursement provided in accordance with the methodology described in Section II. II. The Department' s fee schedule for Licensed Professional Counselors' Services is determined: A. In accordance with the Resource Base Relative Value Scale RBRVS) methodology, by multiplying Medicare' s Relative Value Units ( RVU) , which is numeric, by the Montana Medicaid specific conversion factor, which is a dollar amount, to equal a fee. Specific to Montana Medicaid, there is an ability to multiply the fee times a policy adjuster ( either plus or minus) to affect the fee. B. Resource based relative value scale ( RBRVS) " means the version of the Medicare resource based relative value scale contained in the physicians' Medicare Physician Fee Schedule adopted by the Centers for Medicare and Medicaid Services ( CMS) . C. Relative value unit ( RVU) " means a numerical value assigned in the resource based relative value scale to each procedure code used to bill for services provided by a health care provider. The relative value unit assigned to a particular code expresses the relative effort and expense expended by a provider in providing one service as compared with another service. TN 13- 032 ApprovedSEP 23 201iffective 07/ 01/ 13 Supersedes TN 12- 013

Page 2 of 2 Attachment 4. 19B Methods & Standards For Establishing Payment Rates, Service 6 ( d) Licensed Professional Counselors' Services D. The RVUs are adopted from the RBRVS. For services for which the RBRVS does not specify RVUs, the Department sets those RVUs as follows: 1) The RVUs for a Medicaid covered service are calculated as follows: i) if Medicare sets RVUs, the Medicare RVUs are applicable; ii) if Medicare does not set RVUs but Medicaid sets RVUs, the Medicaid RVUs are set in the following manner: A) convert the existing dollar value of a fee to an RVU value; B) evaluate the RVU of similar services and assign an RVU value; or C) convert the average by report dollar value of a fee to an RVU value. E. If there is not a Medicare RVU or Medicaid history data, reimbursement will be ` by report' , ' By report' means paying a percentage of billed charges. The percentage is derived by dividing the previous state fiscal year' s total Medicaid reimbursement for services included in the RBRVS by the previous state fiscal year' s total Medicaid billings. The ` by report' methodology will end by 6/ 30/ 14. E'. The agency' s rates were set as of the date on the Attachment 4. 19E Introduction Page and are published on the agency' s website www. mtmedicaid. org. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private providers. TN: 13- 032 Approved: Z6ifective: 07/ 01/ 13 Supersedes TN 12- 01. 3 SEP 2',3

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13- 032 Montana I FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT( MEDICAID) I I TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 07/01/2013 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT( Separate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 1902(a)( 30)( A) a. FFY 13 $ 8,851( 3 months) b. FFY 14 $ 51,876( 12 months) c. FFY 15 $ 75,443( 9 months) 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Pages 1 & 2 OR ATTACHMENT( IfApplicable): Attachment 4. 19B Pages 1& 2 Methods& Standards for Establishing Payment Rates Attachment 4. 19B Service 6.d I Methods& Standards for Establishing Payment Rates Licensed Professional Counselors' Services Service 6.d Licensed Professional Counselors' Services i 10. SUBJECT OF AMENDMENT: Increase the rate approximately 2% and update the date of the fee schedule on the Attachment 4. 19B Introduction Page. 11. GOVERNOR' S REVIEW( Check One): j GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 11 SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Montana Dept of Public Health and Human Services A0111 13. TYPED NAME: Mary F. alton Mary E. Dalton Attn: Jo Thompson 14. TITLE: State Medicaid Director He Box 4 Helena MT 59604 15. DATE SUBMTITED: MY- 17s DA= hl',* y Fs sii. itlN ONIVOU, 19. P OF fit qtr t 1 13I? CIAL. J` d<" A` ° k° f€m. ti%, r;; , is. N; nu^ r3' ` k aL is n.< e t i, "' 90E. GZ', S 3,;: t t4 .. j, S w, fi 1 Efa 1; FS a . Y"''^ a° , 7 wg, ,. •{ k£' z+G. i, cm, ab, ,{ e ,,,.. x, t" s' , 3. 3s . „ shy , . €" aR''' M, , a: J' F d '' ba r „ s 9 Lx x<. sss ; 3a s pY' 3 F( 1RM T4rFA- 17U M7- 971

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

September 23, 2013

Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620

Re: SPA MT-13-033

Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-033. This SPA increases rates 2% and changes the date the agency's rates were set for Licensed Clinical Social Workers’ Services.

Please be informed that this State Plan Amendment was approved today with an effective date of July 1, 2013. We are enclosing the CMS-179 and the amended plan page(s).

If you have any questions regarding this SPA please contact Cindy Smith at 303-844-7041.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

Cc: Richard Opper Duane Preshinger Jo Thompson

Page 1 of 2 Attachment 4. 19E Methods & Standards For Establishing Payment Rates, Service 6 ( d) Licensed Clinical Social Workers' Services MONTANA I. Reimbursement for Licensed Clinical Social Workers' Services shall be: A. The lower of: 1. The provider' s * usual and customary charge for the service; or 2. The reimbursement provided in accordance with the methodology described in Section Il. II. The Department' s fee schedule for Licensed Clinical Social Workers' Services is determined: A. In accordance with the Resource Base Relative Value Scale RBRVS) methodology, by multiplying Medicare' s Relative Value Units ( RVU) , which is numeric, by the Montana Medicaid specific conversion factor, which is a dollar amount, to equal a fee. Specific to Montana Medicaid, there is an ability to multiply the fee times a policy adjuster ( either plus or minus) to affect the fee. B. " Resource based relative value scale ( RBRVS) " means the version of the Medicare resource based relative value scale contained in the physicians' Medicare Physician Fee Schedule adopted by the Centers for Medicare and Medicaid Services ( CMS) . C. " Relative value unit ( RVU) " means a numerical value assigned in the resource based relative value scale to each procedure code used to bill for services provided by a health care provider. The relative value unit assigned to a particular code expresses the relative effort and expense expended by a provider in providing one service as compared with another service. TN 13- 033 Approved ..SEQ 101 Effective 07/ 01/ 13 Supersedes TN 12- 012 v

Page 2 of 2 Attachment 4. 19B Methods & Standards For Establishing Payment Rates, Service 6 ( d) , Licensed Clinical Social Workers' Services D. The RVUs are adopted from the RBRVS. For services for which the RBRVS does not specify RVUs, the Department sets those RVUs as follows: 1) The RVUs for a Medicaid covered service are calculated as follows: i) if Medicare sets RVUs, the Medicare RVUs are applicable; ii) if Medicare does not set RVUs but Medicaid sets RVUs, the Medicaid RVUs are set in the following manner: A) convert the existing dollar value of a fee to an RVU value; B) evaluate the RVU of similar services and assign an RVU value; or C) convert the average by report dollar value of a fee to an RVU value. E. If there is not a Medicare RVU or Medicaid history data, reimbursement will be ' by report' , ' By report' means paying a percentage of billed charges. The percentage is derived by dividing the previous state fiscal year' s total Medicaid reimbursement for services included in the RBRVS by the previous state fiscal year' s total Medicaid billings. The ' by report' methodology will end by 6/ 30/ 14. F. The agency' s rates were set as of the date on the Attachment 4. 19B Introduction Page and are published on the agency' s websate www. mtmedicaid. org. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private providers. TN 1. 3- 033 Approvedll* P 2. 3 2013 Effective 07/ 01/ 13 Supersedes TN 12- 012

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 093" 193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: j 2. STATE STATE PLAN MATERIAL 13- 033 Montana 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE FOR: HEALTH CARE FINANCING ADMINISTRATION I SOCIAL SECURITY ACT( MEDICAID) TO: REGIONAL ADMINISTRATOR 444iO-i6S— Ed-EFF-EC—T-1—VE—DAT--E--' HEALTH CARE FINANCING ADMINISTRATION 07%01.'2013 01,12013 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT jepa 6. FEDERAL STATUTE/REGULATION CITATION: 1 7. FEDERAL BUDGET IMPACT: 1902( a)( 30)( A) a. FFY 13 $ 4753 ( 3 months) b. FFY 14 $ 28, 270( 12 months) c. FFY 15 $ 41, 745 ( 9 months) 8. 9 AGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: . PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Pages I & 2, Attachment 4. 1913 OR ATTACHMENT( IfApplicable): Methods& Standards for Establishing Payment Rates Pages I & 2, Attachment 4. 19B Supplement to Attachment 3. 1 A, Page 2 of 4 Methods& Standards for Establishing Payment Rates Supplement to Attachment 3. 1 B, Page 2 of 4 Supplement to Attachment 3. 1A, Page 2 of 4 Service 6.d Supplement to Attachment 3. 1 B, Page 2 of 4 Licensed Clinical Social Workers' Services Service 6.d Licensed Clinical Social Workers' Services 10. SUBJECT OF AMENDMENT: Update the rate by approximately 21N and the update the date ofthe fee schedule on the Attachment 4. 19B introduction Page. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: atio/tt4 Montana Dept of Public Health and Human Services 1 13. TYPED NAME: Mary E. Iton Mary E. Dalton Attn: Jo Thompson 14. TITLE: State Medicaid Director PO Box 4210 Helena MT 59604 15. DATE SUBMITTED: qT14173 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 3 DATE APPROVED: 2013 PLAN APPROVED ONE COPY-AIJACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: SIGN if WIO-f FFICIAI 113 21.—TYPED NAME: 09, L FORM HCFA- 179( 07-92)

Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: MT-13- 0042- MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form ( 179) 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan ( delete if not applicable) TN: MT-13- 0042-MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 CMS Region VIII C' UNTFR FOP MUM M& WDICAID MM R Fs April 8, 2014 Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620 Re: SPA MT- 13- 0042- MM Dear Ms. Dalton: Enclosed is an approved copy of Montana' s state plan amendment ( SPA) 13- 0042- MM, which was submitted to CMS on August 28, 2013. SPA 13- 0042- MM incorporates the MAGI-based mandatory and optional eligibility groups' requirements into Montana' s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is January 1, 2014. We are also sending a copy of the following state plan pages and attachments to be incorporated within a separate section at the end of Colorado' s approved state plan: S14, S25, S28, S30, S32, S33, S50, S51, S52, S53, S54, S55, S57, S59 In addition we will send a summary of the state plan pages which are superseded by SPA 13- 0042- MM, which should also be incorporated into a separate section in the front of the state plan. Superseding pages of state plan material, SPA 13- 0042-MM CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions regarding this SPA please contact Cindy Smith at 303- 844- 7041. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health Operations Cc: Richard Opper, Department Director Duane Preshinger Mary Eve Kulwik Jo Thompson

MT.0250.R00. 00 - Jan 01, 2014 Page 1 of 2 ledicai l state Phan Efi6bilit: Summ:,-,ir Page ( CMS 1 79) State/ Territory name: Montana Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST- YY-0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered MT- 13- 0042 Proposed Effective Date 01/ 01/ 2014 mm/ ddlyyyy) Federal Statute/ Regulation Citation S25: 42 CFR 435. 110; 1902( a)( 10)( A)( i)( 1); 193l( b) and( d)• S28: 42 CFR 435. 116; 1902( a)( 10)( A)( i)( 111) and Federal Budget Impact Federal Fiscal Year Amount First Year 2014 1397665.00 Second Year 2015 2660177.00 Subject of Amendment Implementation of ACA changes for the groups included in the SPAs named above. MAGI budgeting implementation, removal of resource limits and addition of new Former Foster Care children as a covered Medicaid group. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Single Agency Director Review Signature of State Agency Official Submitted By: Mary Eve Last Revision Date: Mar 27, 2014 Submit Date: Aug 28, 2013 TN: MT- 13-0042- MM Approval Date: 03/27114 Effective Date: 01/ 01/ 14 Montana http:// 157. 199. 1 13. 99/ MMDL/faces/ protected/ mac/c01/ print/PrintSelectorjsp 04/ 08/ 2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13- 0042 Montana Pages or sections of pages being superseded by S14, 525, 528, 530, 551, S52, 553, 554, 555, and S57 and related pages or sections of pages being deleted as obsolete State Plan Section Complete Pages Removed Partial Pages Removed Page 1 Page 2, A. 2. b Page 3 Page 2, A. 2. c Page 3a Page 2a, A. 3 Page 4 Page 5, A. 10 Page 4a Page 9c, B. 1 for Page 12 pregnant women and Attachment 2. 2- A Page 13 parents/ caretaker Page 13a relatives Page 14 Page 20, B. 14 Page 14a Page 25, C. 4 Page 21 Page 23 Page 23c Page 23e Supplement 1 to Attachment 2. 2- A Page 1 Page 3b Page 1, A. 2. a( i) and Page lla iii) Page 19 Page 6 related to AFDC Page 19a recipients, pregnant Attachment 2. 6- A Page 19b women, infants, and Page 21 children Page 7, l. a( 1) and ( 2) Page 12, 5. e ( 2) Page 18, 5. e Page 25, 11. a( 3) Supplement 1 to Attachment 2. 6- A Pages 1- 4 Supplement 2 to Attachment 2. 6- A Pages 1- 5 1 TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana

Page 1 Page 3 related to Page 4 AFDC recipients, pregnant women, infants, and children Supplement 8a to Attachment 2. 6- A 8a Addendum related to AFDC recipients, pregnant women, infants, and children Page 1 related to Page la AFDC recipients, pregnant women, infants, and children Supplement 8b to Attachment 2. 6- A Page 2 related to AFDC recipients, pregnant women, infants, and children Supplement 12a to Attachment 2. 6- A Pages 1- 3 Supplement 14 to Attachment 2. 6- A Page 1 2 TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana

Medicaid Eligibility ON413 Control Number 0038- 1148 O'.VIB Expiration date: 10/ 31/ 2014 AFDC Income Standards S14 Enter the AFDC Standards below. All stages must enter: MAGI- equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. MAGI-equivalent AFDC Payment Standard in Effect As ofMay 1, 1988 Income Standard Entry.. Dollar Amount - Automatic Increase Option 13a The standard is as follows: Statewide standard C Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard I TN: MT- 13- 0042- MM Approval Date: 03127/ 14 Effective Date: 01/ 01/ 14 Montana S14, page 1 P, we I of 7

Medicaid Eligibility Additional incremental amount I lousehold size Standard Yes t*, No 1 1 236 x Increment amount S 2 18 x 399 x 4 481 x 5 563 x 6 645 x 7 727 x 8 808 x 851 x 9 110 892 X,l 1 ] 931 x 12 968 x 13 1. 004 x 14 1, 037 x 1, 068 1+ 116 1, 047 x The dollar amounts increase automatically each year C Yes rv N o AITDC Payment Standard in Effect Aus of July 16, 1996 Income Standard Entry- Dollar Amount - Automatic Increase Option SI 3a The standard is as hollows: Statewide standard C Standard varies by region T11. MT- 13- 0042- MM Appiuval Date. OT27114 Effecti ve Bate. 8VOlil, Montana S14, page 2 Pau 2 of' 7

Medicaid Eligibility Standard varies by living arrangement C" Standard varies in some ether way Enter the statewide standard Additional incremental amount Ilousehold size Standard($) Yes ( 9 No j 1 26t Increment amount 2 349 x 3 438 X 4 527 X 5 615 x, 6 703 X 7 792 X 8 880 X•, 9 923 x' j 1 966 x 11 1, 003 X 12 1, 040 1 13 1, 073 14 1, 104 X, 15 1, 134 x; 16 1, 161 I The dollar amounts increase automatically each year 1 Yes t: No MAGI-equivalent A. ".Pa mient Sta ndalyd in Effect AS ofJuly 16, 1996 Income Standard Entry- Dollar Amount - Automatic Increase Optian__ TN: MT- 13- 0042- MM Approval Date: 03127/ 14 Effective Date: 01/ 01/ 14 Montana S14, page 3 Page 3 of 7

Medicaid Eligibility The standard is as follows: i re StateNvide standard C" Standard varies by region C" Standard varies by living arrangement C Standard varies in same other way Enter the statewide standard Additional incremental amount Household size Standard{ S) C' Yes ( No 1 330 x Increment amount 2 442 3 555 4 668 x 5 780 x 6 892 7 1. 005 x f 9 1, 184 X 10 1, 251 x 11 1312 x 12 1, 373 X 13 1, 430 f 14 1, 485 X 15 1, 539 X' 16 1. 590 X' 1 The dollar amounts increase automatically each year r' Yes t: 4 No AFDC; .Need Standard in Effeet As of July 161 1996 Approval Date: 01727li4 Effective Date: Montana S14 4 Page 4 of 7

CMS Medicaid Eligibility s ew. F a M1 snta_3. a x sr.b x44'7''? A Income Standard Entry- Dollar Amount - Automatic Increase Option__.._. ..___- S13a The standard is as follows: C Statewide standard C' Standard varies by region C` Standard varies by ( wing arrangement C" Standard varies in some other way i I I i j The dollar amounts increase automatically each year Yes No I ADC Payment Standard iu Eff"ect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price index for urban consumers( C PI-U) since such date. Income Standard .Entry- Dollar Amount - Automatic,Increase Option S13a` The standard is as follows: Statewide standard C° Standard varies by region C`' Standard varies by living arrangement Standard varies in some other way Enter the statewide standard3 Additional incremental amount Household size Standard($} C yes C No 1 X Increment amount $ .... l E The dollar amounts increase automatically each year C yes C` No MAGI-equivalent AFDC Pay"Mont Standard in effect As ofJuly 16, 1996, increased by no more than the percentage increase in the Consumer Price:Index for urban consumers (C PI-U) since such date Income Standard Entry- Dollar Amount - Automatic Increase Option S13a The standard is as follows: i Statewide standard C` Standard varies by region M Montana Z514, page Pate of 7

Medicaid Eligibility C Standard varies by living arrangement C Standard varies in some other way Additional incremental arnount 2. 204 x The dollar aniOUlItS increase automatically each vear Income Standard Entq- Dollai Amount - Automatic Increase Option Sl3a The standard is as follows: Montana S14. Daae 6 Pa^ 6ol' 7

Medicaid Eligibility p'Y.k CWS. YN+Ml')M`. R w wzYVf A&k#f#p'Yti C` Statew ide standard C Standard varies by region Standard varies by living*arrangement C Standard varies in some other way i i The dollar amounts increase automatically each year C, Yes No M GrI-equivalent TANF payment standard Income Standard entry-'.Dollar Amount - Automatic Increase Option' St3 i The standard is as follows: tom° Statewide standard k C` Standard varies by region C Standard varies by living arrangement Standard varies in some other way i I The dollar amounts increase automatically each year C Yes C No I 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 ON1B control number tar this information collection is 0938 1148. The time required to complete this information collection is estimated to average 40 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 estimates) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop 04..26. 05, Baltimore, Maryland 21244 1850. TN: MT- 13- 0042- MM Approval Date: 03127/ 14 Effective Date: 01/ 01/ 14 Montana S14, page 7 Pap-e 7 of 7

Medicaid Eligibility OMB Control Number 0938- 1148 OMB Expiration date: 10/ 31/ 2014 Eligibility Groups,-,Mandatory Coverage 525 Parents and Other Caretaker Relatives 42 CFR 43 5. 1 10 1902( x)( 10)( A)( i)( I) 1931( b) and( d) Parents and Other Caretaker Relatives- Parents and other caretaker relatives of dependent children with household income at or below- a standard established by the state. The state attests that it operates this eligibility group in accordance with the following provisions: FE] Individuals qualifying under this eligibility group must meet the following criteria: Are parents or other caretaker relatives( defined at 42 CPR 435.4), including pregnant women. of dependent children defined at 42 CFR 435. 4) under age 18. Spouses of parents and other caretaker relatives are also included. The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full- time students in a secondary school or the equivalent level of vocational or technical training. FX Options relating to the definition of caretaker relative( select any that apply): El The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated. m...._........—....._.-.__.__ Definition of domestic partner: i The definition of caretaker relative includes other relatives of the child based on blood( including those of F half-blood), adoption or marriage. m................__. m......_.___.._.._._............__ Description of other Related within 5th degree of kinship to the child by blood, adoption and/or relatives: marriage. f'he definition of caretaker relative includes any adult with whom the child is living and who assumes El primary responsibility for the dependent child' s care. Options relating to the definition of dependent child( select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or C care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent( select the one that applies): TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S25, page 1 age 1 of

Medicaid Eligibility Rm Have household income at or below the standard established by the state. MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S 10 MAGI- Based Income Methodologies, completed by the state. income standard used for this grOLIP N'linimurn income standard The minimum income standard used for this group is the state' s AFDC payment standard in eflect as(.) I'\,],, iy 1, 1988, converted to MAGI- equivalent amounts by hOUSelIOld size. The standard is described in S 14 AFDC Income Stan'—, The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. F-- An attachment is submitted. Maximum income standard The state certifies that it has submitted and received approval for its converted income standard( s) far parents and other caretaker relatives to MAGI- equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. An attachment is submitted. The state' s maximum income standard for this eligibility group is: The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. C , Fhe state' s effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013. converted to a MAGI- equivalent percent of FPt. or amounts by household size. The state' s effective income level for any population of parents"caretaker relatives under a Medicaid I I 15 C demonstration as of March 213. 2010. converted to a MAGI- equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid I 115 dernonstration as of December 31, 2013, converted to a MAGI- equivalent percent ofFPl. or amounts by household size. Enter the amount of the maximum income standard: TN: MT- 13- 0042- MM Approval Date: 03127/ 14 Effective Date: 01/ 01/ 14 Montana S25, page 2 Page 2 of

Medicaid Eligibility s: A?f znrW,wms(,sd' abz kaes9Mr e+ y.4. f Ye5A'# 9 C A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MA(.il-equivalent standard. The standard is described in S14 AFDC Income Standards. lie state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers( CPI- U) since such date, converted to a MAGI- I equivalent standard. The standard is described in S14 AFDC Income Standards. The state' s TANF payment standard, converted to a MAGI- equivalent standard. The standard is described in S 14 AFDC Income Standards. C' Other dollar amount i Income standard chosen: Indicate the state' s income standard used for this eligibility group: C The minimum income standard 6e The maximum income standard The state's AFDC payment standard in effect as ofJuly 16, 1996, increased by rho more than the percentage increase in the Consumer Price Index for urban consumers( CPI- L') since such date. The standard is described in S14 Al' DC. Income Standards. C° Another income standard in- between the minimum and maximum standards allowed There is no resource test for this eligibility group. Vii] Presumptive Eligibility he state covers individuals under this group when determined presumptively eligible by a qualified entity.' The state assures it also covers individuals under the Pregnant Women( 42 CE' R 435. 116) and/ or Infants and Children under Age 19( 42 CFR 435. 1 18) eligibility groups when determined presumptively eligible. Co Yes C No The presumptive period begins on the date the determination is matte. The end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made: or The last day of the month following the month in which the determination of presumptive eligibility is made. if no application for Medicaid is filed by that date. 0 Periods of presumptive eligibility are limited as follows: C No more than one period within a calendar year. No more than one period within two calendar years. No more than one period within a twelve- month period. starting with the effective date of the initial presumptive eligibility} period. TN: MT- 13- 0042- MM ADDrOv Date: 03127/ 14 Effective Date: 01/_01/ 14__ _ Montana S25, page 3 Page 3 of 5

Medicaid Eligibility C Other reasonable limitation: The state requires that a written application be signed by the applicant or representative. C•' Yes CC' No C The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. f The state uses a separate application form for presumptive eligibility, approved by C IS, A copy ofthe application form is included. Au atlarlaii ent is sobttrirted. Fn ' I he presumptive eligibility determination is based on the following factors: F The individual must be a caretaker relative, as described at 42 CFR 4 15. 1 10. Household income must riot exceed the applicable income standard described at 42 CFR 4.15. 110. State residency X Citizenship. status as a national, or satisfactory immigration status I The state uses qualified entities, as clef tried in section 1920A ofthe Act, to determine eligibility presumptively for this eligibility group. List of Qualified Entities S17 A qualified entity is an entity that is determined by the agency to be capable of malting presumptive eligibility determinations based on an individual' s household income and other requirements, and that rneets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state' s approved Medicaid state plan and is eligible to receive payments under the plan Is authorized to determine a child' s eligibility to participate in a Head Start program under the I lead Start Act Is authorized to determine a child' s eligibility to receive child care services for which financial E] assistance is provided under the Child Care and Development Block Grant Act of 1990 Is authorized to determine a child' s eligibility to receive assistance under the Special Supplemental Food Program for Women. Infants and Children( WIC:) under section 17 of the Child Nutrition Act of 1966 Ex Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children' s Health Insurance Program ( CHIP) Is an elementary or secondary school. as defined in section 14101 of the Elementary and Secondary Education Act of 1965 ( 20 IJ. S. C. 88011 E] Is an elementary or secondary,school operated or supported by the Bureau of Indian Affairs Is a state or Tribal child support enforcement agency under title IV- D of the Act TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana S25, page 4 Pap-e 4 of 5

Medicaid Eligibility Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney I lomeless Assistance Act Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title I V- A of the. act Is an organization that determines eligibility for any assistance or benefits provided under any program I of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the united States Housing Act of 1937 W G. S. C. 1437) or under the Native American Housing Assistance and Self Deterinination Act:of 1996( 25 G. S. C. 4101 et seq.) Is a health facility operated by the Indian I lealth Service, a Tribe, or°Tribal organization, or an Urban Indian Organization Other entity the agency determines is capable of making presumptive eligibility determinations: Name of entity Description Any hospital in Montana that accepts Medicaid and/} Hospitals x or CHIP The state assures that it has cornniunicated the requirements for qualified entities, at 1920A( b)( 3) of the Act, and has provided adequate graining to the entities and organizations involved. A copy of the training materials has been included. An attachment is submiftecl. PRA Disclosure Statement According to the Papenvork 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. ' T' he time required to complete this information collection is estimated to average 40 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 torn_please write.to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26- 05, Baltimore, Maryland 21244- 1850. TN: MT- 13-0042- MM Approval Date: 03127/ 14 Effective Date: 01/ 01/ 14 Montana S25, page 5 Page 5 of

Medicaid. Eligibility OMB Control Number13938- 1148 OvIB Expiration date: 10/ 31/ 2014 Tligibility Groups - Mandatory Coverage Pregnant Women 528 i 42 CFR 435. 116 1902( a)( I0)( A)( i)( I11) and( IV) 1902( a)( I0)( A)( ii)( I),( IV) and( IX) 1931( b) and( d) 1920 F Pregnant Women- Women who are pregnant or post-partum, with household income at or below a standard established by the state. The state attests that it operates this eligibility group in accordance with the following provisions: Individuals qualifying tinder this eligibility group must be pregnant or post- partum, as defined in 42 CFR 435. 4. Pregnant women in the last trimester oftheir pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435. 110. t: Yes C No MAGI- based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies. completed by the state. Income standard used for this group Minimum income standard( Once entered and approved by 00S. the minimum income standard cannot be changed.) The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so. C Yes t: No The minimum income standard for this eligibility group is 133° FPL. D Maximum income standard The state certifies that it has submitted and received approval for its converted income standard( s) for pregnant 1Z women to MAGI-equivalent standards and the determination of the nraximuin income standard to be used for pregnant women under this eligibility group. An attachment iv submitted. The state' s maximum income standard for this eligibility group is: The state' s highest effective income level for coverage of pregnant women under sections 1931 ( low- income families), 1902( a)( 100)(i)( 111)( qualified pregnant women). 1902( a)( I0)( A) 6)( IV)( mandatory poverty level- related pregnant wornen), I902(a)( I0)( A)( ii)( IX)( optional poverty level- related pregnant women), I902( a)( 10) A)( ii)( I)( pregnant women who meet AFDC financial eligibility criteria) and 1902( a)( I0)( A)( ii)( IV) institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana S28, page 1 Pate i of 4

MS Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 ( low- income families), I902( a)( I0)(.A)( i)( I11)( qualified pregnant women), I 902( a)( 10)( A)( i)( IV)( mandatory poverty level- related pregnant women), 1902( a)( I0)( A)( ii)( Ik)( optional poverty level- related pregnant women). I902( a)( 10) A)( ii)( 1)( pregnant women who meet AFDC financial eligibility criteria) and 1902( a)( I0)( A)( ii)( IV) institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. The state' s effective income level for any population of pregnant women under a Medicaid 1 1 15 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1 1 15 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of 1, PL. 185°' FPI, Income standard chosen i Indicate the state's income standard used for this cligibility gri>up: C The minimum income standard C The maximum income standard Another income standard in- between the minimum and maximum standards allowed. I he amount of the income standard for this eligibility group is: 157 ° jo FPL, ES] There is no resource test for this eligibility group. Benefits for individuals in this eligibility group consist of the following: I All pregnant women eligible under this group receive full Medicaid coverage under this state plan. C Pregnant women whose income exceeds the income lirnit specified below for full coverage of pregnant women receive only pregnancy- related services. Presumptive Eligibility The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. Yes C No The presumptive period begins on the date the determination is made. Fil 1 he end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made. if an application for Medicaid is tiled by the last day of the month following the month in which the determination of presumptive eligibility is made: or i The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. There may be no more than one period of presumptive eligibility per pregnancy. A written application must be signed by the applicant or representative. Montana S28, page 2 Pasze 2 of 4

Medicaid Eligibility Yes C No C The state uses a single application k)rni for Medicaid and presumptive eligibility. approved by CNIS, The state uses a separate application form for presumptive eligibility, approved by CN4S. A copy of the application form is included. An attachment is su bni iitted. The presumptive eligibility determination is based on the following factors: RE The woman must be pregnant Do Household income Must not exceed the applicable income standard at 42(' 11 R 435. 1 16, State residency Z Citizenship, status as a national, or satisfactory immigration status I' lle state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. List of Qualified Entities S17 A qualified entity is in entity that is determined by the agency to be capable of making PNSUnlpliVe eligibility determinations based on an individual' s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state' s approved Medicaid state plan and is eligible to receive payments under the plan Is authorized to determine a child's eligibility to participate in a Bead Start program under the Head Start Act Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990 Is authorized to determine a child's eligibility to receive assistance tinder the Special Supplemental Food Program for Women, Infants and Children ( WIC) tinder section 17 of the Child Nutrition Act of 1966 Is authorized to determine a child's eligibility tinder the Medicaid state plan or for child health Z assistance tinder the Children's Health Insurance Program( CHIP) Is an elementary or secondary school, as defined in section 14 101 of the Elementary and Secondary Education Act of 1965( 20 U. S. C. 880 1) Is all elementary or secondary school operated or supported by the Bureau of Indian Affairs is a state or Tribal child support enforcement agency under title IV- D of the Act Is an organization that provides emergency food and shelter under a grant tinder the Stewart B. McKinney I lorneless Assistance Act Is a state or Tribal office or entity involved in enrollment in the program tinder Medicaid, CHIP, or 0 title IV- A of the Act TN: MT- 13-0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S28, page 3 Page 3 of 4

f .MS Medicaid Eli i mility Is an organization that determines eligibility for any assistance or benefits provided under any pro Z' gram of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937( 42 US.C. 1437) 0r under the Native American I lousing Assistance and Self Determination Act of 1996( 25 ('!. SC. 4 10 1 ct seq.) Is a health facility operated by the Indian Health Service, a Tribe, or' Fribal organization. or an Urban Indian Organization Other entity the agency determines is capable of making presumptive eligibility determinations: Name of entity Description Community I lealth Centel- or Receive funding under' Ivligrailt I lealth Centers or Public I Icalth Services Primary Community I lealth Centers or Public I lealth Care Research and Demonstration Service Primary C'are Research and Demonstration x Projects Projects( Section 329. Section 300, and section 340 of tile Public I Icalth Services Act) Receives funds under Maternal& Child I iealtli Health Department Services Block Grant( Title V of Social Security x Health Department Participates in the State Perinatal Program Z7 x I lospitals Any hospital in Montana that accepts Medicaid and/ The state assures that it has communicated the requirements for qualified entities, at 1920A( b)( 3) of tile Act, and has provided adequate training to the entities and organizations involved. A copy ofthe training materials has been included. An attachment is submitted. PRA Di-sclosur' -S1a1e e I According m the Paperwork RcdorhonAct o/| 995, 00pc, ao are valid OMB control number. The valid 01MB control number for this information collection is 0938- 1148. TheUmernquiodwcomp| cte this information collection is estimated to average 40 hours per response, including the time to review instructions. search existing data resources, gather( lie data needed, arid complete and review the infbi-mation collection. I f' vou have comments concerning the accuracy nf the tilne es( imate(s) or suggestions for improving this fbrni., please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4' Z6- 0j. Baltimore, Maryland 2| 244'| 8j0, TN: mT' 13- 0042' wM Approval Date: 03/27/ 14 Effective Date: 01m1/ 14 Montana soo. page 4 Po_,e4o[ 4

k tl Medicaid Eligibility OMB Control Number 0938- 1148 OMB Expiration date: 10/ 31' 2014 Eligibility Croups - Mandatory Coverage S30 Wants and Children antler Age 19 42 CFR 435. 1 18 1902( a)( 10)( A)( i)( 111).( IV),( Vi) and( VII) 1902( a)( I0)( A)( ii)( IV) and 0X) 1931( b) and(( I) W Infants and Children under Age 19- Infants and children under age 19 with household income at or below standards established by the state based on age group. file state attests that it operates this eligibility group in accordance with the follotiving provisions: Children qualifying under this eligibility group must meet the following criteria: Are under age 19 I lave household income at or below the standard established by the state. MAGI- based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. Income standard used for infants under age one Minimum income standard The state had an income standard higher than 133°,' o FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. C Yes is No The minimum income standard for infants under age one is 133" FPL. I Maximum income. standard The state certifies that it has submitted and received approval for its converted income standard( s) for infants W underage one to MAGI- equivalent standards and the determination ofthe maximurn income standard to be used for infants under age one. An attachment is submitted. The state' s maximum income standard for this age group is: The states highest effective income level for coverage of infants underage one under sections 1931 ( low- income families), 1902( a)( 10)( A)( i)( 111)( qualified children), 1902( a)( 10)( A)( i)( IV)( mandatory poverty level- related infants), 1902( a)( 10)( A)( ii)( IX)( optional poverty level- related infants) and 1902( a)( 10)( A)( ii)( IV) institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana 30, page 1 PaLle I of 9

Medicaid Eligibility The state' s highest effective income level for coverage of infants under age one under sections 1931 ( low- income families), 1902( a)( l0)( A)( i)( III)( qualified children), 1902( x)( I0)( A)( i)( IV)( mandatory poverty level- related e infants), 1902( a)( 10)( A)( ii)( IX)( optional poverty level- related infants) and 1902( a)( I0)( A)( ii)( IV} institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. fhe state's effective income level for any population of infants under age one under a Medicaid 1 115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. The state's effective income level for any population of infants under age one Under a Medicaid 1 115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of F' PL. 185% FPL Income standard chosen The state' s income standard used for infants under age one is: C The maximum income standard If not chosen as the maximum income standard, the state' s highest effective income level for coverage of infants under age one tinder sections 1931 ( low-income families), 1902( a)( I0)( A)( i)( Il1)( qualified children), 1902( x)( 10) A)( i)( IV)( mandatory poverty level- related infants), I902(a)( I0)(A)( ii)( IX)( optional poverty level- related infants) and 1902( a)( 10)( A)( ii)( IV)( institutionalized children), in effect under the Medicaid state plan as of March 23. 2010. converter{ to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if riot chosen as the maximum income standard, the state' s highest effective income level for coverage of infants tinder age one under sections 1931 ( low- income families), 1902( a)( I0)( A)( i)( 111)( qualified children), 1902( x)( 10) A)(i)( IV)( mandatory poverty level- related infants), 1902( x)( I0)( A)( ii)(IX)( optional poverty level- related infants) and 1902( x)( I0)( A)( ii)( 1V)( institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state' s effective income Level for any population of infants under age one under a Medicaid 1 1 15 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of N/larch 23, 2010, and C if not chosen as the maximum income standard, the state' s effective income level for any population of infants under age one under a Medicaid 1 I I5 demonstration as of' December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in- between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. The amount of the income standard for infants under one is: 143 " a FPL Income standard for children age one through age five, inclusive 0 Minimum income standard TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana 30, page—2 -- PaU),e 2 of 8

Medicaid Eligibility The minimum income standard used for this age group is 1330") FPL,. Maximum income standard The state certifies that it has submitted and received approval for its converted income standard( s) for children Fv age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. An attachment is submitted. The state' s maximum income standard for children age one through five is: The states highest effective income level for coverage of children age one through five under sections 1931 ( low- C. income families), 1902( a)( 10)( A)( i)( 111)( qualified children), 1902( a)( 10)( A)( i)( Vl)( mandatory poverty level- related children age one through five), and 1902( x)( I0)( A)( ii)( IV)( institutionalized children). in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 ( low- income families), 1902( x)( I0)( A)( i)( 111)( qualified children), 1902( a)( I0)( A)( i)( V1)( mandatory poverty level- related children age one through five), and I902( a)( I0)(A)( ii)( 1 V)( institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. The states effective income level for any population of children age one through five Under Medicaid 1 1 15 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid I 1 1 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Enter the amount of the maximum income standard: l4 4, FPL Income standard chosen The state' s income standard used for children age one through five is: i The maximum income standard 1 If not chosen as the maximum income standard, the state' s highest effective income level for coverage of children age one through five under sections 1931 ( low- income families), 1902( a)( 10)( A)( i)( 111)( qualified children), 1902( a)( 10)( A)( i)( V1)( mandatory poverty level- related children age one through five), and 1902( x)( I0)( A)( ii) IV)( institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a NIAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state' s highest effective income level for coverage of children age one through five under sections 1931 ( low-income families), 1902( a)( I0)( A)( i)( Ill)( qualified children), 1902( a)( I 0)( A)( i)( VI)( mandatory poverty level- related children age one through five), and 1902( x)( I0)( A)( ii) 1V)( institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL, TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana 30, page 3 Pate 3 of 8

Medicaid Eligibility. If higherthan the highest effective income level for this age group under the state plan as of March 23, 2010, and C if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1 115 demonstration as of March 23. 2010. converted to a MAGI- equivalent percent of FPL. if higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid I 1 15 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of' FPI..:. Another income standard in- between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age six through age eighteen, inclusive Minimum income standard The minimum income standard used for this age group is 1330,%FPL. Maximum income standard The state certifies that it has submitted and received approval for its converted income standard( s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. i An attachment is submitted. The state' s maximum income standard for children age six through eighteen is: The state' s highest effective income level for coverage of children age six through eighteen under sections 1931 low- income families), 1902( a)( 10)( A)( i)( 111)( qualified children), 1902( a)( 10)( A)( i)( Vll)( mandatory poverty level- related children age six through eighteen) and 1902( a)( I 0)( A)( ii)( IV)( institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a NIAGI- equivalent percent of FPL. The state' s highest effective income level for coverage of children age six through eighteen under sections 1931 low- income families), 1902( a)( I0)( A)( i)( 111)( qualified children). 1902( a)( 10)( A)( i)( V11)( mandatory poverty level- related children age six through cigliteen) and 1902( a)( 10)( A)( ii)( IV)( institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. The state' s effective income level for any population of children age six through eighteen under a Medicaid 1 1 15 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL . C The state's effective income level for any population of children age six through eighteen under a Medicaid I 115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. 133`,; FPL Income standard chosen The state' s income standard used for children age six through eighteen is: TN: MT- 13- 0042- MM Approval Date: 03127/ 14 Effective Date: 01/ 0/ 01/114 Montana 30, page 4 Pau 4 of 8

Medicaid Eligibility The maximum income standard If not chosen as the maximum income standard, the state' s highest effective income level for coverage of children age six through eighteen under sections 1931 ( low- income families), 1902( a)( 10)( A)( i)( 111)( qualified children), 1902( a)( I 0)( A)( i)( VII)( mandatory poverty level- related children age six through eighteen) and 1902( x)( I0)( A) ii)( IV)( institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level liar this age group under the state plan as of March 23. 2010, and i if not chosen as the maxi mam income standard. the state' s highest effective income level for coverage of children age six through eighteen under sections 1931 ( low- income families), 1902( a)( I0)( A)( i)( I1I)( qualified children), 1902( a)( 10)( A)( i)( VII)( mandatory poverty level- related children age six through eighteen) and 1902( x)( I0)( A) ii)( IV)( institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23. 2010. and if not chosen as the maximum income standard, the state' s effective income level for any population of children age six through eighteen under a Medicaid 11 15 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. if higher than the highest effective income level for this age group under the state plan as of'vlarch 23, 2010, and C if not chosen as the maximum income standard, the state' s effective income level for any population of children age six through eighteen under a. Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. C Another income standard in- between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. F There is no resource test for this eligibility group. F Presumptive Fligibility I lee stale covers children when determined presumptively eligible by a qualified entity. Yes C No Presumptive`Eligibility for Children S16 1902( a)( 47) 1920A 42 C' FR 435. 1 101 42 C'TR 435. 1102 The state provides Medicaid coverage to children when determined presumptively eligible by a qualified entity under the following provisions: TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana 30, page 5 Pape 5 of 8

Medicaid Eligibility If the state has elected to cover Optional Targeted Low- income Children ( 42 CFR 435. 229), the income standard for presumptive eligibility is the higher of the standard used for Optional' targeted Low- Income Children or the standard used for Infants and Children under 19( 42 CFR 435. 118). for that child' s age. If the state has not elected to cover Optional Targeted Low Income Children( 42 CFR 435 229), the income standard for presumptive eligibility is the standard used under the Infants and Children under Age I9 eligibility group( 42 CFR 435. 118). for that child' s age. Children under the following age may be determined presumptively eligible: Under age FE] The presumptive period begins oil the date the determination is made. The end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is Tiled by the last day of the month following the month in which the determination of presumptive eligibility is made: or T' he last day of the month following the month in which the determination ofpresumptive eligibility is made, if no application for Medicaid is tiled by that( late. Periods of presumptive eligibility are limited as follows: C No more that) one period within a calendar year. C No more than one period within two calendar years. No more than one period within a twelve- month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes C` N` No C The state uses a single application form fbr• Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by C'MS. A copy of the application farm is included. An attachment is submitted. T' he presumptive eligibility determination is based on the following factors: 0 Household income must not exceed the applicable income standard described above, for the child' s age. State residency Citizenship, status as a national, or satisfactory immigration status The state arses qualified entities. as defined in section 1920A ofthe Act, to determine eligibility presumptively for this eligibility grow f ..,. p Yb p. TN: IT I I DO Appioval Date. 03127M4 Effective Date! OVOV14 Montana 30, page 6 Page 6 of 8

Medicaid Eligibility List of Qualified Entities S17 A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual' s household incolne and other requirements. and that meets at least one of the fbllow ing requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state' s approved Medicaid state plan and is eligible to receive payments under the plan I Is authorized to determine a child' s eligibility to participate in a Head Start program under the I head Start Act Is authorized to determine a child' s eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant: Act of 1990 Is authorized to determine a child' s eligibility to receive assistance under the Special Supplemental Food Program for Women. Infants and Children( WIC) under section 17 of the Child Nutrition Act of 1966 EXI Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children' s Health Insurance Program ( CHIP) Is an elementary or secondary school, as defined in section 14 10 1 of the Elementary and Secondary Education Act of 1965 ( 20 U. S. C. 8801 1) El Is an elementary or secondary, chool operated or supported b the Bureau of Indian Affairs i y, ,. p.,., PP )' E Is a state or Tribal child support enforcement agency under title IV-D of the Act r Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act El Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV- A of the Act Is an organization that determites eligibility far any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States I lousing Act of 1937( 42 U. S. C. 1437) or under the Native American Ilousing Assistance and Self Determination Act of' 1996( 25 U. S. C. 4101 et seq.) i Is a health facility operated by the Indian I lealth Service, a Tribe, or Tribal organization., or an Urban Indian Organization Other entity the agency determines is capable of making presumptive eligibility determinations: Name of entity Description Any hospital in Montana that accepts Medicaid and Hospitals or CHIP J lie state assures that it has communicated the requirements for qualified entities, at 1920A( b)( 1) of the 0 Act. and provided adequate training to the entities and organizations involved. A copy ofthe training materials has been included. An a tachinent is submitted. TN: MT- 13- 0042- MM Approval Date: 03127/ 14 Effective Date: 01/ 01/ 14 Montana 30, page 7 Page 7 of 8

MS Medicaid Eligibility PRA Disclosure Statement According to the Papertivork 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 40 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. TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana 30, page 8 Pap-e 8 of' s

Medicaid Eligibility OMB Control Number 0938- 1148 ONIB Expiration date: 10/ 31'_' 014 Eligibility Groups - Mandatory Coverage S32' Adult Group 1902( a)( I0)(A)( i)( VI11) 42 CFR 435. 119 The state covers the Adult Group as described at 42 CFR 435. 119, Yes No IRA 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 0918- 1148. The time required to complete this information collection is estimated to average 40 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 estimates) 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. TN: MT- 13-0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S32, page 1 Page I of I

Medicaid Eligibility FMB Control Number 0938- 1148 01,413 Expiration date: 10/ 31/ 2014 Eligibility Group - Manoatary averag, 533 Horner Faster tare Children' 42 CFR 435. 150 1902( a)( I0)(A)( i)( IX) Former Foster Care Children- Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster cart, when they turned age 18 or aged out of foster care. The state attests that it operates this eligibility group under the following provisions: Individuals qualifying under this eligibility group must meet the following criteria: Are under aoc 26. I Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. Were in tipster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state' s state plan or I 115 demonstration when they turned 18 or at the time of aging out of that state' s or Tribe's foster care program. The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system. Yes C No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women( 42 CT'R 435. 1 16) and/ or Infants and Children under Age 19( 42 CFR 435. 118) eligibility groups when determined presumptively eligible. Yes No 01 The presumptive period begins on the date the determination is made. J he end date of the presumptive period is the earlier of'. The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made: or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is tiled by that date. j Pcriods of presumptive eligibility are limited as follows: I C No more than one period within a calendar year. C No more than one period within two calendar years. No more than one period within a twelve- month period, starting with the effective date of the initial presumptive eligibility period. C Other reasonable limitation: TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S33, page 1 Pasn* I of 2

Medicaid Eligibility The state requires that a written application be signed by the applicant or representative. t« Yes (" No Fhe state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. The presumptive eligibility determination is based on the following factors: The individual must meet the categorical requirements of 42 CFR 435. 150. X State residency Citizenship, status as a national, or satisfactory immigration status i The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. List of Qualified Entitieg S17 A qualified entity is an entity that is determined by the agency to be capable of tmaking presumptive eligibility determinations based on an individual' s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state' s approved Medicaid state plan and CI is eligible to receive payments under the plan Is authorized to determine a child' s eligibility to participate in a Head Start program under the i I lead Start Act Is authorized to determine a child' s eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990 Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental Food Program for Women. Infants and Children( WIC) under section 17 of the Child Nutrition Act of 1966 Is authorized to determine a child' s eligibility under the Medicaid state plan or for child health X assistance under the Children' s Health Insurance Program ( CI IIP) Is an elementary or secondary school, as defined in section 14 10 1 of the Elementary,and Secondary Education Act of 1965 ( 20 U. S. C. 8801) F' Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs Is a state or Tribal child support enforcement agency under title IV- D of the Act Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Iiomeless Assistance Act Is a.state or] ribal office or entity involved in enrollment in the program under Medicaid, C'I11P, or C title IV-A of the Act TN: MT- 13-0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S33, page 2 pnoo I of i

Medicaid Eligibility Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States housing: Act of 1937( 42 U. S.0 1437) or under the Native American I lousing Assistance and Self Determination Act of 1996( 25 ( J. S. C. 4 10 1 et seq.) Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an 1:71 Urban Indian Organization Other entity the agency determines is capable of making presumptive eligibility determinations: Name of entity Description Any hospital in Montana that accepts Medicaid and/ --- Hospital or CHIP x The state assures that it has communicated the requirements for qualified entities, at 1920A( b)( 3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included. An attachment is sub itteti, 13RA Disclosure Statement o r According to the paperwork Reduction Act of 1995, no persons are required tespond 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 40 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 estimale( s) or suggestions for improving this form, please write tee: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4 26- 05, Baltimore, Maryland 21244- 1 850. TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana S33, page 3 Pnon Z ref Z

MS Medicaid Eligibility e v... . w ws F.. FY M„ sbl¢ sarkSm> w FR OMB Control' N miber 0938- 1148 0118 Expiration date: 10/ 31/ 2014 Eligibility Groups - Options for Coverage 50 Individuals above 133% FPL'. 1902( a)( 10)( A)( ii)( XX) 1902( hh) 42 CFR 435. 219 Individuals above 133% F PL-" T'he state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435. 218. Yes f+ iv o I1 I2. L) isclosure 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 ONIB control number for this information collection is 0938- 11. 49, The time required to complete this information collection is estimated to average 40 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. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S50, page 1 P: Fa<a 1 of t

Medicaid Eligibility 4MB Control Number 0938- 1148 OMB Expiration date: 10/ 31/ 2014 Eligibility Groups - Options for Coverage 551 Optional Coverage of Parents and Other Caretaker Relatives 42 CFR 435. 220 1902( a)( 10)( A)( ii)( I) Optional Coverage of Parents and Other Caretaker Relatives- The state elects to cover individuals qualifying as parentis or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435. 220. i Yes 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. Be time required to complete this information collection is estimated to average 40 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. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana 551, page 1

001- Medicaid Eligibility OMB Control Number 0938- 1148 ONIB Expiration date: 10! 3112014 kligi ility Groups - Options for Coverage S52 Reasonable Classification of Individuals tinder Age 21 42 CFR 435. 22' 1902( a)( 10)(' A)( i i)( 1) 1902( a)( 10)( A)( i i)( I V) Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435. 222. I C Yes ( ' No I 0 The state attests that it operates this eligibility group in accordance with the following provisions: Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria: Be under age 21, or a lower age, as defined within the reasonable classification. Have household income at or below the standard established by the state, if the state has an income standard for the r reasonable classification. Not be cligible and enrolled for mandatory coverage under the state plan. MAGI- based income methodologies are used in calculating household income. Please refer as necessary to S10 V9AG1- 0 Based Income Methodologies, completed by the state. The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 3 I, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher including disregarding all income) than the current mandatory income standards for the individual' s age. C: Yes C" No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23. 2010 with income standards higher( including disregarding all income) than the current mandatory income standards for the individual' s age. is Yes (— No Reasonable Classifications Covered in the Medicaid State Plan as of March 23. ) 010 The state attaches the approved pages from the Medicaid state plan as of March 23, 2010 to indicate the age RI groups, reasonable classifications, and income standards used at that time for this eligibility group, n attachment is submitted. Current_CoveraL)e of All."" CChildren undera Spec.""hied Abe TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 1

Medicaid Eligibility The state covers all children under a specified age limit, equal to or higher than the age limit and/ or income standard used in the Medicaid state plan as of March 23, 2010, provided the income standard is higher than the current mandatory income standard for the individual' s age. The age limit and/ or income standard used must be no higher than any age limit and/ or income standard covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1 115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. C Yes (*- No Current, C' overave of Rea.sonable_CClassifications Covered in the Medicaid State Flan asf March 23, 201.0 The state covers reasonable classifications of children previously covered in the Medicaid state plan as of Marcln 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/ or income standard for this classification covered in the Medicaid state plan as of December 31. 2013 or under a Medicaid 1 1 15 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. Yes (- No Indicate the reasonable classifications of children that were covered in the state plant in effect as of March 23, 2010 with income standards higher than the mandatory standards used for the child's age, using age limits and income standards that are not more restrictive than used in the state plan as of as March 23. 2010 and are not less restrictive than used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1 1 15 Demonstration as of;March 23, 2010 or December 31, 2013. Current_C. ovctaue of Reasonable._CClassifications Covered in the_Medicaid State Plan as f March 3, 20 10 Reasonable Classifications of Children, Sl.l. 0 Individuals for whom public agencies are assuming full or partial financial responsibility. Individuals placed in foster care homes by public agencies Indicate the age which applies: C* Under age 21 (" Under age 20 (— Under age 19 (— t 1nder age 18 Individuals placed in foster care homes by private, non- profit agencies Individuals placed in private institutions by public agencies Indicate the age which applies: 9 hider age 21 C Under age 20 (- Under age 19 (— Under age 18 Individuals placed in private institutions by private, non- profit agencies Individuals in adoptions subsidized in full or part by a public agency Indicate the age which applies: Under age 21 C'' Cinder age 20 C`' I/ rider age 19 tinder age 18 TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 2 PAVo? of' 10

Medicaid Eligibility Individuals in nursing facilities, if nursing facility services are provided tinder this plan Indicate the age which applies: Under age 21 C Under age 20 (' Under age 19 C' Under age 18 Also individuals in Intermediate Care Facilities for Individuals with Intellectual Disabilities( ICF- II D) I if these services are provided under this plan. Indicate the age which applies: Under age 21 C Under age 20 C (11 nder age I') C Under age 18 Individuals receiving,active treatment as inpatients in psychiatric facilities or programs, if' such services are provided tinder this plan FX Other reasonable classifications Name of classification Description Age Limit Under the Individuals receiving active jurisdiction of the treatment as inpatients in Department or are wards of the tribal psychiatric facilities or court and Under the supervision of an (. 111der age 21 indian tribe. BIA or the State of programs Montana Enter the income standard used for these classifications. The income standard must be higher than the mandatory standard for the child's age. It may be no lower than the income standard used in the state plan as of March 23, l- 20 10 and no higher than the highest standard used in the Medicaid state plan as of December 3 1, 2013 or tinder a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Click here once S1 1 form above is complete to view the income standards form. Individuals placed in foster care homes b* public agencies Income standard used F Minimum income standard The minimum income standard for this classification of children is the AFDC payment standard in effect as of.Jtjly 16, 1996, not converted to MAGI- equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard N,o income test was used( all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31. 2013. Yes No TN: MT- 13-0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 3

Medicaid Eligibility The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI- equivalent standards and the determination of the maximum income standard to be used forth is classification of children l.rrnder this eligibility group. An attachnient is su initted The state' s maximum income standard for this classification of children( which must exceed the minimum for the classification) is: The state' s effective income level for this classification of children under the Medicaid state plan as of March 23. 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state' s effective income level for this classification of children under the Medicaid state plan C as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. The state' s effective income level for this classification of children under a Medicaid 1 1 1 Demonstration as of March 23. 2010. converted to a MAGI- equivalent percent of FPL, or amounts by household size. The state' s effective income level for this classification of children under a Medicaid 1115 C Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- C equivalent standard. This standard is described in Sid AFDC income. Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state' s TANF payment standard, converted to a MAGI- equivalent standard. This standard is C described in S 14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount Income Standard E# trY- Dollar Am6unt - Automatic Increase Option 5132 The standard is as follows: t Statewide standard C" Standard varies by region Standard varies by living arrangement C Standard varies in some other way TN: MT- 13-0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 4 NP0, 4 of' 0

Medicaid Eligibility Enter the statewide standard Additional incremental amount Household size Standard( S) C Yes C" No I 453 X Increment amount ; 2 607 x 3 761 X 4 916 x 5 1, 070 X' 6 1, 225 7 1, 380 x j 18 1, 533 X' 9 1, 637 x 10 1, 740 11 1, 836 12 1. 934 X 13 1026 x 14 It 16 X? 15 2, 204 16 2, 290 X The dollar amounts increase automatically each year Yes (*- No Income standard chosen Individuals qualify under this classification In}der the following income standard: C The minimum standard. i The maximum income standard. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 5 Pnoo i of" 0

Medicaid Eligibility If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective incomee level used under the Medicaid state plan as of March 23, 2010, the state' s effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL, or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state' s effective income level for this classification under a Medicaid 1 l 15 Demonstration as of March 23, 2010. converted to a VIAG1- equivalent percent of FPL or amounts by household size. i If not chosen as the maximum income standard, and if higher than the effective income level used C under the Medicaid state plan as of March 23, 2010, the states effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Individuals placed in private institutions by';public agencies FO-] Income standard used Minimum income standard The minimum income standard for this classification of children is the AFDC' payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent.' this standard is described in S14 AFDC Income Standards. Maximum income standard No income test was used( all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid I 1 15 Demonstration as of March 23, 2010 or December 31. 2013. C Yes (- 9 No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the F maximum income standard to be used for this classification of children trader this eligibility group. An attachment is submitted. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 6 Paor- F, of" h

Medicaid Eligibility The state' s maximum income standard for this classification of children( which must exceed the minimum for the classification) is: The state' s effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. The state' s effective income level for this classification of children under the Medicaid state plan C" as of December 31. 201: 3. converted to a MAGI- equivalent percent of FPL or amounts by household size. The state' s effective income level for this classification of children undera Medicaid 1 115 C Demonstration as of March 23, 2010, converted to a. MAGI- equivalent percent of FPL or amounts by household size. fhe state' s effective income level for this classification of children under a Medicaid 1 1 l5 C Demonstration as of December 31, 2013. converted to a MAGI- equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: C A percentage of the federal poverty level: uo The state' s AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S 14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state' s TANF payment standard, converted to a MAGI- equivalent standard. This standard is C" described in S 14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. s Other dollar amount Income, Standard Entry' - Dollar.A.wnonnt - Automatic Increase Option ; S,13a The standard is as follows: 1: Statewide standard Standard varies by region Standard varies by living arrangement CStandard varies in some other way Enter the statewide standard TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 7 Prior 7 ni"Ifl

MS Medicaid Eligibility Additional incremental amount Household sire Standard($} C Yes +` No i 1 453 X Increment amount 71 2 607 x 3 761 x E, i 4 916 x I' I 5 1. 070 x 6 1. 225 X' 7 1, 380 8 1, 533 x' 9 1, 637 10 1. 740 Y 11 1, 836 12 1, 934 13 2, 026 X i 14 2. 116 X i 15 2. 204 x 16 2, 290 The dollar amounts increase automatically each year C Yes {: No Income standard chosen Individuals qualify under this classification under the following income standard: C The minimum standard. t: The maximum income standard. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 8

Medicaid Eligibility If not chosen as the maximum income standard, the state' s effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used j C under the Medicaid state plan as of March 23, 2010, the state' s effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state' s effective income level for this classification under a Medicaid 11 l S Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used C under the Medicaid state plan as of March 23, 2010, the states effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 201. 7, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in- between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Individuals in adoptions subsidized in full or part by a public agency Income standard used Minimum income standard The minimum income standard far this classification of children is the AFDC' payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S 14 AFDC Income Standards. Fm Maximum income standard No income test was used( all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid I 1 15 Demonstration as of March 23, 2010 or December 31, 2013. 79, Yes C No No income test was used( all income was disregarded) for this classification under: check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1 115 Demonstration as of March 23, 2010. TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 9 P 9 of A

Medicaid Eligibility f A Medicaid 1 1 I5 Demonstration as of December 31, 2013. The state's maximum standard for this classification of children is no income test( all income is disregarded). Income standard chosen Individuals qualify Linder this classification under the following income standard: This classification does not use an income test( all income is disregarded). Individuals in nursing; facilitic§, if nursing facility services are provided under this plan Income standard used Minimum income standard The minimum income standard for this classification of children is the AFDC payment standard in effect as of July I6, 1996, not converted to MAGI- equivalent. This standard is described in S 14 AFDC Income Standards. 0 Maximum income standard No income test was used( all income was disregarded] for this classification either in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1 1 15 Demonstration as of March 231 2010 or December 31. 2013. Yes : No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI- equivalent standards and the determination of the Z maximum income standard to be used for this classification of children under this eligibility group. An attachment is submitted. The state' s maximum income standard for this classification of children( which must exceed the minimum for the classification) is: The state' s effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL, or amounts by household size. The state' s effective income level for this classification of children under the Medicaid state plan as of December 3 1, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state' s effective income level for this classification of children under a Medicaid I I I5 C Demonstration as of March 23, 2010. converted to a MAGI- equivalent percent of FPL or amounts by household size. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01101/ 14 Montana S52, page 10 pnoi- I fl of' IC

Medicaid Eligibility The state' s effective income level for this classification of children Linder a Medicaid I 115 C Demonstration as of December 31, 2013, converted to a- MAGI- equivalent percent of f, PL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state' s AFDC payment standard in effect as Of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S 14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state' s' TANI' Payment standard, converted to a MAGI- equivalent standard.' This standard is C described in S 14 AFDC Income Standards.' I his option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount lneikfie$ n1lard f,## ry- Dollar Amount = Aiutomatk Increase Option S13a The standard is as follows: Statewide standard C Standard varies by region C Standard varies by living arrangement C Standard varies in some other way Enter the%taiewide tandard TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 11 D"", I I of If.

Medicaid Eligibility Additional incremental amount Household size Standard{$) Yes *' ' Uo 1 453 x Increment amount 5 2 607 x 13 61 3 4 916 X' 1. 070 x' 6 1. 225 X 7 1, 380 8 1, 533 x 9 1. 637 X I 10 1. 740 11 1, 836 1 12 1, 934 x 13 2, 026 X 14 1116 i 15 2. 204 x I 16 2, 290 X The dollar amounts increase automatically each year C Yes i No income standard chosen Individuals qualify under this classification under the following income standard: C The minimum standard. Ce The maximum income standard. TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 12 P-. I'? M, -if

Medicaid Eligibility If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state' s effective income level for this classification under the Medicaid state plan as of December 3 I, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state' s effective income level for this classification under a Medicaid I 1 15 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used C under the Medicaid state plan as of March 23, 2010. the states effective income level for this classification under a Medicaid 1 1 15 Demonstration as of December 31, 2013. converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in- between the minimum and maximum standards allowed, provided it is C higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Also individuals in Intermediate Care Facilities for Inaividuals with Intellectual iiisabilities( I.CF41D), if these services alre provided render this plan. Income standard used J Minimum income standard The minimum income standard for this classification of children is the AFDC payment standard in effect as of.luly 16, 1996, not converted to MAGI- equivalent. This standard is described in S 14 AFDC Income Standards. F_ Maximum income standard No income test was used( all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid I 1 15 Demonstration as of March 23, 2010 or December 31. 2013. C Yes t'+ N o The state certifies that it has submitted and received approval for its converted income standards for this classification of children to%/IAGI- equivalent standards and the determination of the maximurn income standard to be used for this classification of children under this eligibility group. An attachment is submitted. TN: MT- 13-0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 13 Pane 13 of{,

Medicaid Eligibility The state' s maxim1.lrn income standard for this classification of children( which must exceed the minimum for the classification) is: The state' s effective income level for this classification of children Linder the Medicaid state plan t+ as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. The state' s effective income level for this classification of children under the Medicaid state plan CC as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. The state' s effective income level for this classification of children under a' Medicaid 1 1 15 C" Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. The state' s effective income level for this classification of children under a Medicaid 1 1 15 C Demonstration as of December 31, 2013. converted to a NIAGl- equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: C° A percentage of the federal poverty level: o The state' s. AFDC payment standard in effect as of July 16, `1996, converted to a MAGI- C.., equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state' s TANF payment standard, converted to a MAGI- equivalent standard. This standard is described in S 14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount Income Standard Entry w Dollar Amount - Automatic Increase Option S,13a The standard is as follows: C: Statewide standard C" Standard varies by region C Standard varies by living arrangement C" Standard varies in some other way Enter the statewide standard TN: MT- 13- 0042- MM Approval Date: 03/ 27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 14

Medicaid Eligibility w, 8k. b4eF+#( FfiHKaYR. k& JRrt.:L} tkk. Additional incremental amount Household size Standard Yes : No 1 453 X Increment amount 1 E- 2 607 X I f 3 761 x 4 916 X 1, 070 x' f 6 1. 225 x; 7 1, 380 8 1, 533 _ X 9 1, 637 X I 10 1, 740 X I 1 1, 836 12 1, 934 13 2,026 X' 14 1116 15 204 i 16 2, 290 x.' The dollar amounts increase automatically each year Yes (— No Income standard chosen Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 15 t' af, e I of' IC

MS Medicaid Eligibility If not chosen as the maximum income standard, the state' s effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of ITIL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used C under the Medicaid state plan as of March 23, 2010, the state' s effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent ofFIRL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used C' under the Medicaid state plan as of March 23, 2010, the state' s effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FTL or amounts by household size. If' not chosen as the maximum income standard, and if higher than the effective income level used C under the Medicaid state plan as of March 23, 20 1 O the state' s effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPIL or amounts by household size. Another income standard in- between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of 1%, larch 23, 2010, converted to a MAGI equivalent. Individuals receiving'active treatment as inpatients in psychiatric facilities or programs FE] Income standard used Minimum income standard The Minimum income standard for this classification of children is the AFDC payment standard in effect as of'July 16, 1996, not converted to MAGI- equivalent. This standard is described in S 14 AFDC Income Standards, Fm Maximum income standard No income test was used( all income was disregarded) for this classification either in the Medicaid state plan as of December it, 2013, or under a Medicaid I 115 Demonstration as of' March 23., 2010 or December 31, 201 C Yes (*- No The state certifies that it has Submitted and received approval for its converted income standards for this classification of children to MAGI- equivalent standards and the determination of the R-1 maximum income standard to be used for this classification of children Linder this eligibility group. EAn attachment is submitted. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 16

Medicaid Eligibility The state' s maximum income standard for this classification of children( which must exceed the minimum for the classification) is: T'he state' s effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. The state' s effective income level for this classification of children under the Medicaid state. plan C as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. The state' s effective income level for this classification of children under a Medicaid 1115 C Demonstration as of March 231 2010, converted to a. MAGI- equivalent percent of FPL or amounts by household size. The state' s effective income level for this classification of children under a Medicaid 1 1 15 C Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: C A percentage of the federal poverty level: 0/lo The state' s AFDC payment standard in effect as ofJLily lb, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state' s TANF payment standard, converted to a MAGI- equivalent standard. This standard is C` described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the. Adult Group. C+` Other dollar amount I.ncoime 5tandar / / fury - Dollar Amount -. Attttomatic increase Option IS13a The standard is as follows: C- Statewide standard C Standard varies by region C Standard varies by living arrangement i Standard varies in some other way Eater the statewide. standard TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 17

Medicaid Eligibility Additional incremental amount Household size Standard($) C Yes No 1 453 Increment arnount S 2 607 x I 3 761 x I 4 916 x e 5 1, 070 x i 6 1. 225 X 7 1, 380 x' 8 1, 533 X 9 1. 637 x 10 1, 740 x 11 1. 8; 6 i i 12 1, 934 x E 113 2,026 X 14 1116 x' 15 2.204 3(' 16 90 The dollar amounts increase automatically each year C Yes (: No 0 Income standard chosen Individuals dualifyy under this classification under the following income standard: t The minimum standard. The maximum income standard. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 18

MS Medicaid Eligibility If not chosen as the maximum income standard. the state' s effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state' s effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010 the states effective income level for this classification under a;Medicaid 1 115 Demonstration as of March 23, 2010. converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state' s effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is t higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Other Reasonable C`lassitications Previously Covered The state covers reasonable classifications of children r» t.covered in the Medicaid state plan as of March 23, 2010, but covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1 115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age group. C Yes (: No Additional r_te_w awe rUUt?s or_reasonable_classifications covered_ If the state has not elected to cover the Adult Group( 42 C' FR 435. 1 19), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is riot available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage. The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted to a MAGI-equivalent standard. Yes ( No There is no resource test for this eligibility group. PRA Disclosure Statement TN: MT- 13-0042- MM Approval Date: 03127/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 19 D-, 10- 471P

Medicaid Eligibility According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection of in unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09-18- 1148, The time required to complete this information collection is estimated to average 40 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 04'ficer, Mail Stop C4- 26- 05, Baltimore, Maryland 2 1244- 1850. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S52, page 20

m Medicaid Eligibility OMB Control Number 0938- 1 148 OMB Expiration date: 10/ 31/ 2014 Eligibility Groups- Options for( overage S53 Children with Non 1V-E Adoption Amistanc 42 CFR 435. 227 1902( a)( 10)( A)( ii)( VIII) Children with Non IV- E Adoption Assistance- The state elects to cover children with special needs for whom there is a non I V- E adoption assistance agreement in effect with a state, who were eligible for Medicaid. or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435. 227. Yes C` No The state attests that it operates this eligibility group in accordance with the following provisions: Individuals qualifying under this eligibility group} must meet the following criteria: I'he state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; Are under the following age( see. the Guidance for restrictions on the selection of an aec): Under age 21 C Under age 20 Uitder age 19 C Under age I8 MAGI- based income methodologies are used in calculating household income. Please refer as necessary, to SIO MAGI- Based Income Methodologies, completed by the state. The state covered this eligibility group in the Medicaid state plan as of December 3 I, 201 3, or under a Medicaid 1 1 15 Demonstration as of March 23. 2010 or December 31. 2013. t:` Yes (- No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. C+ Yes C No Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement. The state used an income standard or disregarded all income f6r this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1 115 Demonstration as of March 23, 2010 or Decernber31, 2013. 1 Yes C No Income standard used for this eligibility group i Minimum income standard The minimum income standard for this eligibility group is the AFDC payment standard in effect as of.luly 16. 1996. not converted to MAGI- equivalent. This standard is described in S14 AFDC Income Standards. i Maximum income standard TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S53, page 1 V<...::, 1 , 4-

Medicaid Eligibility No income test was used( all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1 115 Demonstration as of March 23, 2010 or December 31, 2013. t Yes C No No income test was used( all income was disregarded) for this eligibility group under j cheek all that apply): F The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1 1 15 Demonstration as of>t4arch 23, 2010. F] A Medicaid 1 1 15 Demonstration as of December 31, 2013. The state' s maximum standard for this eligibility group is no income test( all income is disregarded). Fm] Income standard chosen Individuals qualify under this eligibility group under the following income standard, which must be higher than the minimum for this child' s age: I This eligibility group does not use an income test( all income is disregarded). There is no resource test for this eligibility group. 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 OVIB control number for this information collection is 0938- 1148. The time required to complete this information collection is estimated to average 40 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. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S53, page 2

Medicaid Eligibility n'\-1B Control Number 0938- 1148 OMB Expiration date: 10/ 31/ 2014 Eligibility Groups - Options for Coverage 554 Optional Targeted Low Income Children 1902( a)( 10)( A)( ii)( XIV) 42 CUR 435. 229 and 435. 4 1905( u)( 2)( B) Optional"Targeted Low Income Children- The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CUR 435. 4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CUR 435. 229. Yes (— No The state attests that it operates this eligibility group in accordance with the following provisions: Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group. MAGI- based income methodologies are used in calculating household income. Please refer as necessary,to S 10 MAGI- Based Income Methodologies, completed by the state. The state covered this eligibility,group in the state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes (— No The state also covered this eligibility group in the state plan as of March 23, 2010. Yes C No Until October 1, 2019, states must include at least those individuals covered as of March 23, 2010, but may cover additional individuals. Effective October 1, 2019, states may reduce or eliminate coverage for this group. Individuals are covered under this eligibility group, as follows: C" All children under age 18 or 19 are covered: I he reasonable classification of children covered is: Under age 1 Age I through age 5, inclusive Age 6 through age 18, inclusive Under age C Age 7 through age El Income standard used for this classification Minimum income standard IN: MI- 13- UU42- MM Approval a e: J Montana S54, page 1

Medicaid Eligibility Flie income standard for this classification of children Must exceed the lowest income standard chosen for children in the age group selected above_ tinder the mandatory Infants and Children tinder Age 19 eligibility group. Maximum income standard The. state certifies that it has StIbIllitied and received approval for its converted income standard( s) for this classification of children to MAGI- equivalent standards and the determination of the maximum income standard to be used for this classification of children tinder this eligibility group. An attachment is submitted. The state' s Inaxiniturt income standard for this classification of' children( which must exceed the minimum for( fie classification) is: The state's effective income level for this classification of' children tinder the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPI.... The state' s effective income level for this classification of' children tinder the Medicaid State Plan as of' December 31, 2013, converted to a MAGI- equivalent percent of FPL. The. he state' s effective income level for this classification of children tinder a Medicaid I 115 demonstration as of' March 23, 2010, converted to a MAGI- equivalent percent of FPL. The he state' s effective income level for this classification of children tinder a Medicaid I 115 demonstration as ot' December 31, 2013, converted to a MAGI-equivalent percent of FPL. 200",6 FPL, C A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section I I 0( b)( 4) of the Act, but by no more than 50 percentage points. The state's maximum income standard for this classification of children( which must exceed the Ik minimum for the classification) is: F1473, ]% FP I., Income standard chosen, which must exceed the minimum income standard Individuals qualify tinder the following; income standard: I Z11 9 The maximum income standard. C , I I lie state' s effective income level for this eligibility group under the Medicaid state plan as of March 23, 1010, converted to a MAGI- equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, the state' s effective income level for this eligibility group tinder the Medicaid state plan as of December 31, 20 13, converted to a MAGI- equivalent percent of FPL. If higher than the effective income level used tinder the , late plan as of March 23, 2010, the state' s effective C income level for this eligibility group tinder a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S54, page 2

Medicaid Eligibility If higher than the effective income level used under the state plan as of March 23, 2010, the state' s effective income level for this eligibility group under a Medicaid l 115 demonstration as of December 31. 2013. converted to a MAGI-equivalent percent of FPL. C° if higher than the effective income level used under the state plan as of March 23, 2010, 2000o FPL. If higher than the effective income level used under the state plan as of March 23, 2010, a percentage of the C FPL which may exceed the Medicaid Applicable Income Level, defined in section 21 10( b)( 4) oft but by no more than 50 percentage points. Another income standard in- between the minimum and maximum standards allowed, provided it is higher than the effective income level For this eligibility group in the state plan as of March 23, 2010. The income standard for this eligibility group is: l43 % FPL here is no resource test for this eligibility group. iJ Presumptive Eligibility Presumptive eligibility for this group depends upon the selection of presumptive eligibility for the Infants and Children under Age ' 19 eligibility group. If presumptive eligibility is done for that group, it is done for this group under the same provisions. 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 OiIN4B 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 40 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 estimates) 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 2 1244- 1850. TN: MT- 13-0042- MM Approval Date: 03127/ 14 Effective Date: 01/ 01/ 14 Montana S54, page 3 Paaea 1 of i

Medicaid Eligibility OMB Control Nurnber 0938- 1148 OMB Expiration date: 10/ 31/ 2014 Eligibility Groups W Options for Coverage S55' Individuals with Tuberculosis 1902( a)( 10)( A)( ii)( xn) 1902( z) Individuals with Tuberculosis- The state elects to cover individuals infected with tuberculosis who have income at or below a standard . established by the state, limited to tuberculosis- related services. Yes (: 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 40 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. TN: MT- 13- 0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S55, page 1

Medicaid Eli ib lity OMB Control Number O93D'\| 48 OMB Expiration dot 10/ 31/ 2014 10SUIT Statement Eligi,bility Groups - Options for Coverage Independent Foster Care Adolescents 42 CFR 435226 Independent Foster Care Adolescents- The state elects to cover individuals under an age specified by the state. less than age 21, who v, ere in state- sponsored loster care on their I 8th birthday and who ineet the income standard established by the state and in accordance with the provisions described at 42 CFR 435. 226, According m the PmycnworkReJucbon Act of\ 995. nnpc000aon required ox respond mo collection o[ information unless i/ displays o valid OMB control number. The valid OMB control number for this information collection isOY] 8-| } 48. The time required mcomplete this in06nnmimn collection iy estimated w average 4O hours per osponsc. including,the( imcm review iny1muions, search existing data resources, gather the data needed, and complete and review the inlormation collection. K you have commeo/ sconcerning the accuracy of' the tirrie estitnate( s) or suggestions for improving this f6m, please write to: CMS. 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4- 26- 05, Baltimore, Maryland 21244- 1850. TN: mT- 13' 0042' Mm Approval Date: 03127/ 14 Effective Date: 0101n4 Montana oa. pagel

ms Medicaid Eligibility OMB Control Number 0938- 1148 OMB Fxpiration date: 10/ 31/ 2014 Eligibility Groups - Options for Coverage,; S59 Individuals Eligible for Family Planning Services 1902( a)( 10)( A)( i i)( XX 1) 42 CFR 435. 214 Individuals Eligible for Family Planning Services- The state elects to cover individuals who are not pregnant. and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435. 214. Yes + 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 40 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. TN: MT- 13-0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana S59, page 1 t ac7< 1 nf i

It ' a Uv**A ?'! Proof of Temporary Coverage for Presumptive Eligibility Dear Provider: The person( s) listed below has temporary health coverage through Presumptive Eligibility ( PE). Temporary coverage may last between 30 and 60 days depending on the effective date of coverage shown ( below). To ensure payment, providers must verify eligibility prior to providing services and submitting claims. If you have questions concerning Presumptive Eligibility, please call the Human and Community Services office, 1- 877- 543- 7669, ext.2869 OR ext. 3098. Verify Presumptive Eligibility via: Web Portal at www. mtmedicaid.org( click on Montana Access to Health link); FAX Back at 1- 800-714- 0075( do not FAX the completed PE application to this FAX number); or Automated Voice Response at 1- 800- 714- 0060 Services included under temporary coverage are the same as those available under regular program coverage. NOTE: Social Security Numbers are requested but are not required. Social security Effective Check the appropriate coverage group Name Number AND Date Former Parent/ Pregnant Breast& First- Middle Initial- last) Date of Birth of Coverage HMK Foster Care Caretaker Woman Cervical mm/ dd/ yyyy mm/ dd/ yyyy Plus HMK ( ages 18 up Relative Cancer to 26) Medicaid I i i I I I E I Name of Qualified Entity Determining Presumptive Eligibility( Please Print) Date Signature of Qualified Entity QUALIFIED ENTITY: Within 5 days of Determination, SCAN PE Application and Proof of Temporary Coverage form, then create a secure ePass account at transfer.mt.gov, and email scanned documents to: HHSPresum tive mt, ov— OR FAX same documents to: 1- 877- 418-4533. Human and Community Services Division, State of Montana, PO Box 202925, Helena MT 59620-2925 TN: MT- 13-0042- MM Approval Date: 03/27/ 14 Effective Date: 01/ 01/ 14 Montana

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Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: MT- 13- 0044-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan TN: MT- 13- 0044- MM Approval Dat 11/ 1- 5/ 201 Effective Date 10/ 011/2-013

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 CMS tk'+ lt blEtlit, 4t: 1ift7lL:.•tlE) S3 t41C: C Region VIII November 26, 2013 Mary Dalton, Medicaid& Health Services Manager Montana Department of Health& Human Services 1400 Broadway PO Box 202951 Helena, MT 59620 Re: SPA MT- 13- 0044- MM Dear Ms. Dalton: Enclosed is an approved copy of Montana' s state plan amendment ( SPA) 13- 0044-MM, which was submitted to CMS on August 28, 2013. SPA 13- 0044- MM incorporates the MAGI-based eligibility process requirements into Montana' s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013. Enclosed is a copy of the following S94 state plan pages and attachments to be incorporated within a separate section at the end of Montana' s approved state plan: S94, pages S94- 1 and S94- 2 Appendix A and Appendix B In addition, enclosed is a summary of the state plan pages which are superseded by SPA 13- 0044- MM, which should also be incorporated into a separate section in the front of the state plan. Superseding pages of state plan material, SPA 13- 0044- MM. CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Cindy Smith of my staff at ( 303) 844- 7041 or by email at Cindy.Smith@cros.hhs.gov. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health Operations Cc: Richard Opper, Department Director Duane Preshinger Jo Thompson

Medicaid State Mari Eligibility: Sti.rnrnary Page ( C MS 1, 79) State/Territory name: Montana Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST- YY-0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered MT13-044MM Proposed Effective Date 10/ 01/ 2013 mm/ dd/ yyyy) Federal Statute/Regulation Citation 42 CFR 435, Subpart J and Subpart M Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment 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. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Single Agency Director Review Signature of State Agency Official Submitted By: Jo Thompson Last Revision Date: Nov 21, 2013 Submit Date: Aug 28, 2013

4- 0'* 0Cmis Medicaid Eligibility OMB Control Nurnber 0938- 1148 OMB Expiration ( late: 10223 1 201. 1 General Eligibility Requirements S94 Eligibility Process 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishina Medicaid. Application Processing Indicate which application the agency uses for individuals applying R) y coverage who may be eligible based on the applicable modified adjusted gross income standard. The he single, streamlined application for all insurance aftbrclability prograrns, developed by the Secretary in accordance with FX section 141 3( b)( I)( A) of the Affordable Care Act An alternative single. streamlined application developed by the state in accordance with section 1413( b)( I)( B) of the E] Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submi.tted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the F agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through Such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the stale and El approved by the Secretary, and supplemental Forms to collect additional inforniation needed to determine eligibility on such other basis, submitted to the Secretary. F- An atlacbment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which Z' minimizes the I) L1rdCr1 on applicants., submitted to the Secretary. An attachment is submitted The agency' s procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR .4) 5. 1200( t). by telephone, via inail. and in person. The agency also accepts applications by other electronic means: Yes No I........................... I...................... TN: MT- 13-0044- MM Approval Date: 11/ 25/ 2013 Effective Date: 10/ 1/ 2013 Montana S94, page l P-- I

Medicaid Eligibil=ty Indicate the other electronic means bclo v: Name of klethod Description Montana' s online application apply. ml. gov- online self-service portal. x The agency has procedures to take applications. assist applicants and perform initial processing ot' applications for[ lie eligi i it groups listed below at locations other than those used lor the receipt and processing ofapplications fior the title IV- A program, including 1: edcrally-qualified health centers and disproportionate share hospitals. Parents and Other Caretaker Relatives Pregnant Women Infants and Children Under A- e 19 Redetermination Processing Redeterminations of eli ibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows. consistent with 42 CFR 435. 916: Once every 12 months Without requiring information from the individual if able to do so based on reliable information contained in the iridividu;.-d' s account or other more current information available to the aocncv I f the agency cannot determine eligibility solely on the basis of the inforniation available to it, or otherwise needs additional information to complete the redetermi nation, it provides the individual Nvith a pre- pOpUlated rcnewal form containing the information already available. Redeterminations of eligibility for individuals whose financial eligibility is not based oil the applicable modified ad,justed gross income standard are perfi)rnie'd, consistent with 42 CIFR 435. 916( check all that apply): Once every 12 months Once every 6 months Other, more often than once every 12 JT1011thS Coordination of Eligibility and Enrollment I he stale rnects all the requirements of' 42 CF-R 435, Subpart \ 1 relative to coordination ofeligibility and enrollment betwecii Z Medicaid. CI IIP, Exchanges and other insurance afTordability programs. The single state agency has entered into agrecinents with the Exchan, le and with other aacricies administering insurance affordability programs. PRA i According to ( lie Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid UNB control number. The valid OMB control number for this information collection { s890'| l4C. The time required mcoo`p| me this information collection is estimated to average 40 hours per response, including the time to review instructions., scarch existing data resources, gather the data needed, and complete and review| ho iu6znnxiion collection. If you have comments concerning the accuracy of' the time estimon( x) o, suggestions for improving this k/ rm, please write to: CMS, 7500 Security Boulevard. Attn: PNA Reports Clearance Officer, Vlui| SmpC4' 26'& 5, Baltimore, Maryland 21244- 1850. TN: wT' 13- 0044- wm Approval Date: 11/ 25u013 Effective Date: 10/ 1o013 Montana sn4. page z o..~ ).,,

Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: MT- 13- 0045-MM This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan TN: MT- 13- 0045- MM Approval Dat 06/ 10/ 2015 Effective Date 01/ 01 ?{) 14

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1961 Stout Street, Room 08-148 Denver, CO 80294 CcMS Region VIII June 11, 2015 Mary Dalton, Medicaid & Health Services Manager Montana Department of Health& Human Services 1400 Broadway PO Box 202951 Helena, MT 59620 Re: SPA MT- 13- 0045- MM Dear Ms. Dalton: We have reviewed the proposed MAGI State Plan Amendment ( SPA) submitted under transmittal number MT- 13- 0045- MM. This SPA implements the Affordable Care Act ( ACA) changes for citizenship and non-citizen eligibility, verifying the reasonable opportunity periods to provide verification of citizenship. The SPA also confirms who may qualify as a non-citizen under section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act PRWORA) of 1996. Please be informed that this State Plan Amendment was approved on June 10, 2015 with an effective date of January 1, 2014. We are enclosing the summary page and the amended plan page( s) with attachments. If you have any questions regarding this SPA please contact Cindy Smith at 303- 844-7041. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health Operations Cc: Richard Opper, Department Director Duane Preshinger Jo Thompson Mary Eve Kulawik

MT.0253. R00.00 - Jan 01, 2014 Page 1 of 2 Medicaid State Plan 1-1 i ibiliw Stimmary Pace (CMS 17 tn State/Territory name: Montana Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST-YY-0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered MT- 13- 0045 Proposed Effective Date 01/ 01/ 2014 mm/ dd/ yyyy) Federal Statute/ Regulation Citation 1902( a)( 46)( B); 8 USC 1661, 1612, 1613 and 1641; 1903( v)( 2),( 3) and( 4); 42 CFR 435. 4; 42 CFR 435. 406; 42 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment Implementation of ACA changes for citizenship and non- citizen eligibility, verifying the reasonable opportunity periods to provide verification of citizenship. The SPA also confirms who may qualify as a non- citizen under section 403 of PRWORA. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Sincle Agency Director Review Signature of State Agency Official Submitted By: Mary Eve Last Revision Date: Jun 8, 2015 Submit Date: Aug 28, 2013 TN: MT- 13- 0045- MM Approval Date: 6/ 10/ 15 Effective Date: 01/ 01/ 14 https:Hwms- mmdl.cdsvdc.com/MMDL/faces/ protected/ mac/ c01/ print/PrintSelector jsp 06/ 11/ 2015

Medicaid Eligibility OMB Control Number 0938- 1148 OMB Expiration date: 10; 3112014 Non-flloa neini tiilgih1111y S89 Citizenship and Scan-Citimi Eligibility 1902( a)( 46)( B) 8 U. S. C. 1611, 1612, 1613, and 1641 1903( v)( 2),( 3) and( 4) 42 CFR 435. 4 42 CFR 435. 406 42 CFR 435. 956 Citizenship and Non-Citizen Eligibility The state provides Medicaid to citizens and nationals of the United States and certain non- citizens consistent with requirements of 42 CFR 435. 406, including during a reasonable opportunity period pending verification of their citizenship. national status or satisfactory immigration status. F The state provides Medicaid eligibility to otherwise eligible individuals: Who are citizens or nationals of the United Stages; and 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. I612(b)) and is not prohibited by section 403 of PRWORA ( 8 U. S. C. § 1613); and 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), 1902( ee) of the SSA and 42 Cf,R 435. 406, and 956. 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 verification process. Yes (— No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. 9 Yes fi' No The date benefits are furnished is: C The date of application containing the declaration of citizenship or immigration status. C The date the reasonable opportunity notice is sent. Other date, as described: Land/ or irst day of the month of the application containing the declaration of citizenship immigration status. TN: MT- 13- 0045- MM Approval Date: 6/ 10/ 15 Effective Date: 01/ 01/ 14 Pane 1 of 3

Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non- Citizens whose eligibility is not prohibited by section 403 of PRWORA 8 U. S. C. § 1613). C Yes C* No Indicate which requirements apply: The state requires Lawful Permanent Residents to have 40 qualifying work quarters under Title 1I of the Social Security Act. o Yes, C- No The stale limits eligibility to 7 years for certain non-citizens. C: Yes C No Check all that apply: Non- citizens admitted to the U. S. as a refugee under section 207 of the INA Non- citizens granted asylum under section 208 of the INA Non- citizens whose deportation is withheld under section 243( h) or 241( b)( 3) of the INA Non- citizens granted status as a Cuban- Haitian Entrant, as defined in section 501( e) of the Refugee Education Assistance Act of 1980 Non- citizens admitted to the U. S. as Amerasian The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903( x)( 4) of the Act. Yes C` No Pregnant women Individuals under age 21: C°t Individuals under age 21 C Individuals under age 20 Individuals under age 19 An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. An individual is considered to be lawfully present in the United States if he or she: 1. Is a qualified non- citizen as defined in 8 U. S. C. 1641( b) and( c); 2. Is a non- citizen in a valid nonimmigrant status, as defined in 8 U. S. C. 1101( a)(] 5) or otherwise under the immigration laws( as defined in 8 U. S. C. 1 101( x)( 17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U. S. C. 1182( d)( 5) for less than I year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings, 4. Is a non- citizen who belongs to one of the following classes: TV MT- 13-0045- MM Approval Date: 6/ 10/ 15 Effective Date: 01/ 01/ 14 Pap-e 2 of 3

Medicaid Eligibility R Granted temporary resident status in accordance with 8 U. S. C. 1 160 or 1255x, respectively; Granted Temporary Protected Status(' I-PS) in accordance with 8 U. S. C. § 1254a, and individuals with pending applications for" FPS who have been granted employment authorization; Granted employment authorization under 8 CFR 274a. 12( c); 0 Family Unity beneficiaries in accordance with section 301 of Pub. L. 101- 649, as amended; Under Deferred Enforced Departure( DF.,D) in accordance with a decision made by the President, Granted Deferred Action status; Granted an administrative stay of removal under 8 CFR 241; 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 Is under the age of 14 and has had an application pending for at least 180 days; 6. 1las been granted withholding of removal under the Convention Against' Ibrture, 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U. S. C. 1 101( 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)); 10. Fxc.ept,i n: 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( I) through( 9) of this definition. Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, riot related to an organ transplant procedure, as defined in 1903( v)( 3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/ or present an SSN: Qualified non- citizens subject to the 5 year waiting period described in 8 U. S. C. 1613; i Non-qualified non- citizens, unless covered as a lawfully residing child or pregnant woman by the state under( lie option in accordance with 1903( v)( 4) and implemented at 435. 406( b). 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 f'or this information collection is 0938- 1148. The time requires( to complete this information collection is estimated to average 40 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. TN: MT- 13- 0045- MM Approval Date: 6110/ 15 Effective Date: 01/ 01/ 14 Page 3 of 3

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13- 0045 MM Montana PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT( IfApplicable): S89 Non- Financial Eligibility- Citizenship and Non- citizen Eligibility Attachment 2. 6- A: Page 2, item( 3), paragraphs( a),( b),( c),( d),( e) and( f), TN 10- 011 Attachment 2. 6- A: Page 3, item( 3), paragraphs( f)( 1),( f)(2), f)(3),( f)(4) and( g), TN 10- 011 TN: MT- 13-0045- MM Approval Date: 6/ 10/ 15 Effective Date: 01/ 01/ 14

QUALIFIED NON-CITIZENS SUBJECT TO 40 WORK QUARTERS REQUIREMENT Attachment to S89) TRANSMITTAL NUMBER: STATE: 13- 0045- MM Montana In addition to Lawful Permanent Residents listed on page 2, Montana requires the following Qualified Non-Citizens to have 40 qualifying work quarters under Title II of the Social Security Act as a condition of Medicaid eligibility: Battered non- citizens, who meet the conditions set forth at 8 U. S. C. 1641( c) Non-citizens granted conditional entry under §203( a)( 7) of the INA in effect before April 1, 1980 Non-citizen granted parole for at least one year under §212( d)( 5) of the INA TN: MT- 13- 0045- MM Approval Date: 6/ 10/ 15 Effective Date: 01/ 01/ 14 FORM HCFA- 179( 07- 92)

Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: MT- 13- 0048-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan TN: MT- 13- 0048- MM Approval Dat 1111-5/ 2-011 Effective Date 01, 101/ 201 ,

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services IM AN MdPaftW 1600 Broadway, Suite 700 Denver, CO 80202-4967 1W W CIN'THS17}t ME Olt W k Region VIII November 26, 2013 Mary Dalton, Medicaid & Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620 Re: SPA MT- 13- 0048- MM Dear Ms. Dalton: Enclosed is an approved copy of Montana' s state plan amendment ( SPA) 13- 0048-MM, which was submitted to CMS on August 28, 2013. SPA 13- 0048- MM incorporates the MAGI-based Single State Agency Delegation of Authority requirements into Montana' s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013. Enclosed is a copy of the following Al-A3 state plan pages and attachments to be incorporated within a separate section at the end of Montana' s approved state plan: Al-A3, pages 1- 13 Attorney General' s Statement Organizational Chart In addition, enclosed is a summary of the state plan pages which are superseded by SPA 13- 0048- MM, which should also be incorporated into a separate section in the front of the state plan. Superseding pages of state plan material, SPA 13- 0048- MM. CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Cindy Smith of my staff at ( 303) 844-7041 or by email at Cindy.Smith@cros.hhs.gov. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health Operations Cc: Richard Opper, Department Director Duane Preshinger Jo Thompson

MT.0256. R00. 00 - Oct 01, 2013 Page 1 of 2 7vle'dicaifi State Plan J.,Ji,,ibi1itv. SinninarY, Page ( CNIS 179) State/Territory name: Montana Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST-YY-0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered MT 13- 048 M M Proposed Effective Date 10/ 01/ 2013 mm/ dd/ yyyy) Federal Statute/ Regulation Citation 42 CFR 43 1. 10, . 11 and. 12; 42 CFR 431. 50 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment Implementation of ACA and update of designation and authority of the State Agency and use of Federal funds. Also includes the designation of the Federal Facilitated Marketplace( FFM) as a determiner of eligibility for ACA programs. The FFM will also will be designated to conduct fair hearings on the ACA decisions made. The SPAs indicate the State and any other agencies in Montana that determine eligibility and conduct fair hearings on Medicaid decisions. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Single State Agency Review Signature of State Agency Official Submitted By: Jo Thompson Last Revision Date: Nov 25, 2013 Submit Date: Aug 28, 2013 httn-// 157. 199. 1 1399/ MMDI,/faces/ protected/ mac/ c01/ nrint/PrintSelector.isp 11/ 25/ 2013

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: MT 13- 048MM Montana PAGE NUMBER OF THE PLAN SECTION OR COMPLETE PAGES PARTIAL PAGES ATTACHMENT: SUPERSEDED: SUPERSEDED: Al —A3 Page 1 Section 1. 4( page 9)( State Medical Care Advisory Section 1. 1 ( pages 2- 6) Committee only. Tribal consultation will remain in the Section 1. 2( page 7) state plan.) Section 1. 3 ( page 8) Attachment 1. 1- A( Attorney General certification) Attachment 1. 2- A Organizational chart) Attachment 1. 2- B( Description of the functions of the single state agency) Attachment 1. 2- C( Description of professional medical and supporting staff) Attachment 1. 2- D

Medicaid Administration. OVIB Control Nurnber 09.18- 1148 0\ 113 Expiration date: 10/ 31 ' 01 1 Stag Plan Administration Al Designation and Authority i 42 CFR 431. 10 Designation and Authority i State Name: Flontana As a condition for receipt of I ederai funds under title XIX of the Social Security Act, the single state agency named helow" submits Cher following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. 3 i 1 Name ol' single state agency: Montana Department of Public I Iealth and Human Ser, ces Type of Agency: C Title IV- A Agency C Health r` Iluman Resources C: Other Type of Agency ' Heald? " Title.IV- A I he above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act.( All references in this plan to " the Medicaid agency" mean the agency named as the single state agency.) The state statutory citation for the legal authority under which thee single state agency administers the state plan is: S; 6- 101 Montana Code Annotated I he single state agency supervises the administration ofthe state plan by local political subdivisions. C" Yes No The certrtication signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration ofthe program has been provided. An attachment is submitted. The state plan may be administered solely by the single state agency, or sonic portions may be administered by other agencies. The single state agency administers the entire state plan under title XIX( i. e., no other agency or organization administers any portion of it). Ce' Yes (,... No pprova ate: ec ive a e: Montana Al- A3, page 1 Pacer' t of 12

Medicaid Administration The entity or entities that have responsibility for deterrilinal.ions of eligibility for fanlilieS, adults. and ('or individuals under 21 are: he Medicaid agency Sin- le state agency under Title IV-A( in the 50 states or the District of Columbia) or Under' Title I or XVI ( AABDI) in Guam, E.] Puerto Rico, or the Virgin Islands An Exchang)c that i s a government agency established under sections 13 11( b)( I) or 1321( c)( I) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: Z The Medicaid agency Sin- le state agency under' Title IV-A( in the 50 states or the District of Columbia) or under' Title I or XVI (,AABD) in Guam. Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 13)11( b)( 1) or 132 1( c)( I) of the Affordable(" are Act The Federal agency administering the SSI program Indicate which agency determines eligibility for any groups whose eligibility is not determined by the federal agency: Medicaid agency E] Title I V- A agency El Ail E'xchange ZI The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are: Medicaid agency An Exchange that is a government agency established under sections 13 11( b)( I) or 1321( c)( 1) of the AIIZ)i dable Care Act An Exchange appeals entity, including an entity established under section 1411( 1) of the. Affordable Care Act Name of entity: Office 44arketpl .. The agency has established a review process whereby the agency revieNks appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but Only with respect to conclusions of law, including interpretations of state or federal policies. Yes ( i No State Plan Administration Organization and Administration 42 CFR 43 1. 10 42 CFR 43 IJ I Organization and Administration Provide a description of the organization and ftinctions of the Medicaid agency. See attached organizational chart. Montana State Medicaid Oraanization and Functions of the Single State Agency TNI- NAT- 43. 00-48 NUA ApprGyal Date; 1112W43 Montana Al- A3, page 2 ll,we 2 of 13

MS Medicaid Administration. Montana DeparFr ent ofPublic T} ea to and Human Services ( DPI Director' s Office hhe Director was appointed by the Governor to oversee the agency' s employees, contracts and major programs. DPI 11 is the largest agency of state government.. lie is responsible for overall department policy development, managennent, and coordination of programs. I The Director' s Office of the DPI HS provides professional support to the agency' s three branches and 1' division,,. 'I three branches are Operations Services, Medicaid and Health Services and Economic Security Services. the Director' s Office is made up of the Department Director; the Office of Legal Affairs;. the f luman Resources Office; the Prevention Resource Center; Office of Governmental Support, and the Public Information Office. Office ofof Legal Affairs I he Office of Legal Affairs is part of the Director' s Office of the Montana Department of Public I lealth and Human Services DPHIiS), which is an executive agency of the State of Montana and Montana' s single Medicaid and CI l IP agency. The Office of( Legal Affairs is staffed by attorneys licensed to practice in Montana and support staff. It provides legal services to DPI It IS' three branches and 12 divisions. Medicaid and Health Services Addictive and Nientai Disorders Division( AMDD) The division provides chemical dependency and adult mental health services by contracting with behavioral health providers throughout Montana. It also provides services through three inpatient facilities-the Montana State Hospital in Warm Springs, Montana Chemical Dependency Center in Butte, and Montana Mental Health Nursing Care Center in Le.vvistown. I I Through the Chemical Dependency Bureau,. AMDD assesses the need for chemical dependency treatment and prevention services throughout Montana. Those services are available through contracts with 18 state- approved programs. The bureau reimburses for a . 1 full range of outpatient and inpatient services, as well as an education program for DIM offenders. The bureau also organi/ es and funds activities designed to prevent the use of alcohol, tobacco, and other drugs by youth and the abuse ofthose substances by adults. People with substance abuse disorders who have family incomes below 200 percent ofthe federal poverty level are eliLjhlc for public funding of treatment services. In addition, the Medicaid program funds outpatient and residential chemical dcpendenc, treatment for adolescents who are Medicaid eligible. ii The Mental Health Services Bureau is responsible for the development and oversight: of the state' s system fi3r delivering and reimbursing publicly funded. Adult.Mental Health Services. The bureau ensures the availability and efficient delivery of appropriate and effective services. The bureau also provides extensive monitoring ol' program iniplenrentatiorn and operation as wcli as analysis and reporting of program operations, costs, and outcomes. Consumers eligible for services include adult Medicaid recipients and other low- income Montanans with severe disabling mental illness. Developmental Services Division The Developmental Disabilities Program contracts with private, non- profit corporations to provide services across the lifespart for individuals who have developmental disabilities and their families. The focus of the program is to tailor care to the individual and provide it in as natural environment as possible. The Montana Developmental Center is administered by the Developmental Disabilities Program and is the States only residential facility for individuals with developmental disabilities that provides 24- hour care for those vvitlr the most severe behaviors or severe self help deficits. i he Children' s Mental Health Bureau provides care and support to individuals under 18 years of age who have been diagnosed with serious emotional disturbance( SED). I ealth Resources Division The Iicalth Resources Division( tiRD) administers Medicaid Physician, Acute and Iiospital!Clinic health care services for low income and disabled Montanans and oversees the benefits of tine Healthy; Montana Kids Plan. The division provides administration. policy development, and reimbursement for primary and acute portions of the Medicaid program. TN: MT- 13- 0048- MM Approval Date: 11/ 25/ 13 Effective Date: 10/01/ 13 Montana ATA3, page P' w" "'sof13

Medicaid Administration e r cute ,_'Civic'-; Bureau manages the ' ie rear programs# or borne in usion t erapy. c enta services, ura e nice rca equrprrzent. school- based services, eyeglasses, audiology, therapies_prescription drugs, and transportation. T'he I Icalthv Montana Kids( NMK) Plan provides free or low-cost health coverage for children up to age 19 in families who cannot i afford other health insurance. 1 1he I lospitai and Clinical Services Bureau manages the Medicaid inpatient and outpatient hospital services, Indian health services end- stage renal disease services, ambulatory surgical centers, freestanding dialysis clinics, federally qualified health centers. rural health clinics, and critical access hospitals. The Managed Care Bureau manages the Medicaid programs for physician- related services. including claims management and resolution, provided by physicians, mid- level practitioners, podiatrists, laboratories, chiropractors, respiratory therapists, and nutritionists. I' he Montana Medicaid managed- care program is known as PASSPORT to Health. In 2001_ the bureau implemented a new program known as Nurse First. It provides assistance to Medicaid recipients with chronic conditions, such as diabetes, asthm r and heart conditions. Through a telephone hotline, it also helps all Medicaid clients make appropriate decisions about the level of medical care they need in any given situation. Senior and Long Term Care Division The division administers aging services, adult protective services, and the state' s two veterans' homes. It also helps to fund care fut elderly and disabled Montanans who are eligible for Medicaid and Supplemental Security Income.( SSI). j The Office on Aging develops a State Plan on Aging and approves service delivery plans and programs developed by 10 Area Agencies on Aging located across Montana. Among the services provided by the area agencies are senior centers, Meals on t4'hc l5. I, health services. transportation, home chore services, and information referral and assistance services. The Office on Aging houses the Long-Term Care Ombudsman, Elderly Legal Assistance, State Health Insurance and Assistance Program ( SHIP). NVe are looking for Montana Centenarians. The Long-Term Care Ombudsman is an advocate for all residents of lon_;-texm care facilities, especially nursing homes and personal care horses. The ombudsman can provide information or direct assistance related to the health. safety. and rights of i residents. The Legal Services Devcloper Program provides training for seniors, farnily members, and others on elder-specific laws. The program develops pro- bono and local legal service referrals, training materials, and telephone assistance to seniors. The State Health Insurance Program( SHIP) provides Medicare and related health insurance information, counseling, assistance and advocacy to Montana Medicare beneficiaries, their family members, caregivers, and local professionals. statewide source of I program information for beneficiaries of Medicare, Medicaid, Medicare supplemental policies, long-term care insurance. arid other health insurance benefits. i The Information, Assistance and Referral Program is a service designed to link Montana seniors, their farnily members. and l caregivers with needed services. Eighty-two technicians work through the local Area Agencies oil Aging to provide information about service, make proper referrals, and do public education and out reach within their communities. The Adult Protective Services Program employs 36 social workers across the state whose duties include investigating allegations of abuse, neglect, and exploitation for the elderly and people with disabilities. They also arrange for and coordinate a variety of I support services aimed at protecting vulnerable people from abuse and neglect. i The Medicaid Community Services Program pays for personal care, skilled nursing care, home health aides. home dialysis attendants, and hospice care for elderly and disabled people eligible for- Medicaid. file I Ionic and Community Based Services Program contracts with case managers in local communities to arrange for an arrav of in-home services to enable people in need of care to avoid a stay in a hospital or long-terra care facility. The Medicaid Nursing Facility Services Program pays for short-term and long-teen nursing care for individuals eligible for i NIe N aldT` 03Q049= mlt of nursing care beds in M(AppemcWaircidbenddMitaugh Medicaid. Effective Date: 10/01/ 13 on ana page Pare 4 off!

Medicaid .Administration 0 Gf ro# f akY .. N.. n ^ dthw'.e Fhe State Supplemental Payments Program supplements the Social Security Supplemental Security Income( SSI) of elgib3e individuals who live in designated residential care facilities. These facilities include community homes for individual i-vith developmental or mental disabilities, group homes for individuals with severe disabilities, personal care homes, licensed foster homes, and transitional living homes. i Economic Security Services Human& Community Services Division( HC' SD) 1 he division provides cash assistance, employment training, supplemental nutrition assistance( formerly food stamps), Medicaid eligibility, child care, meal reimbursement, nutrition training.,energy assistance, weatherization, and other services to help families move out of poverty and toward self-support. I he division determines eligibility for: Medicaid programs for children. pregnant women, the elderly, the disabled, and other eligible adults. Cash assistance is funded by a federal block grant called Temporary Assistance for Needy Families( IANF). The program provides monthly payments to love- income families and children who meet income and resource eligibility standards. The Work Readiness Component( WoRC) provides employment and training services to individuals receiving;cash assistance. The Supplemental Nutrition Assistance Program ( SNAP, formerly the Food Stamp Program) provides benefits to eligible families to supplement their food budget and increase their ability to purchase healthy foods. A SNAP Nutrition Education( SNAP- Ed), operated jointly with Montana State University, teaches participants to use their food stamp benefits wisely. Through its child-care programs. HCSD helps low- income working and TANF families pay for child care so they can work or take advantage of training and educational opportunities that prepare them for work. It also helps child-care providers improve their quality of care by providing training incentives, nnentoring, and grant programs. The Child and Adult Care Food Program( CACFP) Montana' s Early Childhood Services Bureau and its Best Begimnins s qualitti child care programs recognize nutrition as an important element in child care. The Child and Adult Care Food Program tC_`,,V P) k; ; the State agency' s child nutrition, administrative and financial expertise that provides policy and guidance 16r menus, meals and j I food service management in child care. The CACFP provides reimbursement for meals served in participating institutions when those meals meet federal L' S Department of Agriculture( ISDA) regulations and align with the cut-rent Dietary Guidelines for Americans. The CACFP is available to infants, children, and impaired or older adults enrolled in institutions that participate it) the i I CACFP. Eligible institutions are family day care homes, child care centers, afterschool and outside school hours facilities, adult d ny care facilities, and emergency shelters. The Head Start State Collaboration project provides a vital link between Head Start and state programs to help build early childhood j systems and access to comprehensive services and support for all low- income children. The Lokv Income Energy Assistance Program( LIEAP) provides heating assistance to loss- income people, while The W'eatherizrtton Program supplies the labor and materials needed to make homes more energy efficient. Through its Commodities Distribution Program, HCSD delivers nutritional foods to*\ lontana' s Indian reservations, food banks. j emergency- feeding organizations, and senior centers. It also provides montlily food packages to low- income women. children, and seniors. The division administers a federal Community Services Block Grant to find local projects aimed it addressing the causes of poverty, as well as a I Iomeless Grant to help local shelters and I Inman Resource Development Councils provide: lodging for individuals and families who are without, or at risk of being without, housing. Disability Employment and Transitions Division j The division is advancing the employment, independence, and transitions of Montanans with disabilities. Employment in a competitive integrated setting; Independence grounded in self-determination informed choice, and consumer control; ant] Transitions from high school to post- secondary education and work that are collaborative and successful. i, Three bureaus make up Disability Employment and Transitions: Montana Vocational Rehabilitation and Blind- Low Vision Field Sel— Tkem-P--0(3 0M r8- Wport, and Disability Determi4* i-ouaf t3eteee11/ 25/ 13 Effective Date: 10/01/ 13 Montana page Pace of 1

Medicaid Administration. Child Support Lnforcernent Division(( SED) 1 he division provides federally mandated child support enforcement services. These include: i Locating absent parents, Establishing paternity: Establishing financial and medical support orders:. I Enforcing current and past-due child support: Offering medical and spousal support; and Modifying child support orders. i Administrative decisions of the division can be appealed through judicial review by a district court. Individuals who receive public assistance under the Temporary Assistance to Needy Families( I' A VF) program are automatically referred to CSED. Support owed to the family is automatically assigned to the state as a condition of'TANF. When the child support is collectecL it is used to reimburse the state and federal governments for welfare benefits paid to the family. Individuals who do not receive public assistance may apply for division services. [ n non- TANK cases, child support collections uc forwarded to the custodial party. Other states refer cases to Montana for action when a 11011- custodial parent lives in Montana. CSED also collects parental contributions to the state for foster care placements. A i In February 2010, CSED implemented the ReliaCardix\ isaR prepaid dcbit card. The CSED will electronically load child support payments into the cardholder' s ReliaCard account whenever payments are received. The Re.liaCard requires no credit approval, bank account or previous banking relationship and is issued free of charge by Ii.S. Bank directly to the claimant. The card fives claimants quick and easy access to their funds and eliminates waiting for paper checks and check- cashing fees. Claimants can use their card to make purchases in stores, online, pay bills or get cash hack with purchases. The division is made up of six bureaus: Administrative Services, Field Services, Program and Training, Legal Services, Budget and i the Office of the Administrative Law Judge( OALJ). Central prograrn administration, the OALJ, and the Interstate Regional Office are located in Helena. Four additional regional offices are located in Butte, Billings, Great Falls, and Missoula. j Child& Family Services Division( CFSD) The division provides state and federally mandated protective services to children who are abused, neglected, or abandoned. This includes receiving and investigating reports of child abuse and neglect, working to prevent dornestic violence, helping families to stay together or reunite, and finding placements in foster or adoptive hornes. The division operates a toll- free child abuse hotline 24 hours a day. 7 days a week. Centralized Intake specialists screen calls, assess i the level Of risk to children, and prioritize reports of abuse. neglect, and abandonment according to the urgency with which Social workers need to respond. ' The specialists forward reports of suspected child abuse, neglect, or abandonment((.; social workers in county offices for investigation. I Social workers investigate reports and help parents find solutions to problems that may interfere with their children' s safety. I f the parents are amenable, the social workers can help the family 4et in- home service,, such as home management skill trainirt parenting education classes, modeling skills for parents, and supervised visitations." These can be provided directly by ( t SD social workers or by private agencies on contract with the division. Division policy is to provide protective services to children in their . l own homes when it is possible to do so without risking their safety. To help family members become involved in addressing the care and safety of their children, the division uses Family Group Decision- making Meetings.' These meetings bring together family, friends, social workers, and service providers to share concerns, I knowledge, and skills. They can be used throughout the child protective process- as a wav to prevent removal of a child from the home. after the child is in foster care, to document family progress in improving the home setting. and to help identify permanent placements for a child. If a social worker determines that a child is in immniediate danger, the child may be placed outside the honk, either permanently or temporarily. District court judgcs must approve all out-of-home placements. Kinship care involves placing the child, whenever possible, with an extended family member, clan member, or tribal member. It provides the child with a safe and nurturing environment while preserving a family connection. When all out-of-home placement is necessary, social workers are required to first try to place the child with a non-custodial birth parent or with a member of the child' s extended family. TN: MT- 13- 0048- MM Approval Date: 11/ 25/ 13 Effective Date: 10/ 01/ 13 Montana Al- A3, page Pant 6 of' 1

Medicaid Administration Under t e ee era n ran i ' e tare Act, Cf must c o its pest to pace nc ran. i c rem m scthngs t gat cncoura; e connectroro with their tribal heritage The act also requires that the child' s tribe and parents get notice of a I I judicial proceedings. TSD family resource specialists recruit and license foster parents to provide substitute homes for children placed away from their parents or guardians. Foster care includes family foster care, group homes, shelter care, and residential facilities. CFSD also licenses specialized and therapeutic family foster homes for children with special needs and child placement agencies, such as adoption agencies. Ideally, the division tries to help improve parents' abilities to care for their children so that children who have been removed from their homes can return as soon as possible. Reunification services include Family Group Decision- mahim-, Nleetings, counseling, parenting education classes, in- home services, mentoring, respite care, supervised visits, and transportation If a court determines that a child cannot be returned to birth or legal parents. a permanency team reviews the child' s circumstances and identities whether adoption, guardianship, placement with a relative, or another living arrangement is the best option. Adoptk-)n is generally the permanency plan of choice when a court terminates parental rights, because adoption offers a child a lifetime link to j I a family. CF-SD administers a subsidized adoption program for children with special needs. Guardianship is an alternative when adoption is not considered to be the best option. Guardianship is a legal relationship that can only be established or dissolved by 11 court. For children ages 16 to? 1 N4,ho are making the transition from taster care to independent living, C: FSD offers a number of services. including housing assistance, counseling, career guidance, education, transportation, money management skills. and financial stipends. i i Public Health and Safety Division The division has four bureaus focused on improving the health of Montanans. Chronic Disease Prevention& Health Promotion Bureau Programs: Arthritis Asthma Cardiovascular Health Program Diabetes Prevention EMS and Trauma systems Injury Prevention Montana Diabetes Project ti1ontana Hospital Discharge Data System Tobacco Use Prevention Cancer Control Program tilontana Breast& Cervical Health Program Montana Comprehensive Cancer Control Program Cancer Surveillance and Epidemiology Program Communicable Disease Control& Prevention Bureau Programs: Communicable Disease Epidemiology Disease Reporting Food& Consumer Safety InUnunization i STD HIV Treatment& Prevention Rape and sexual Assault Prevention Tuberculosis i Family & Community I lealth Bureau Programs: Food and Consumer Safety Program Food Defense and Emery_=envy Preparedness Public Accommodations Retail food Service Establishments Schools, Daycares, Community Homes Swimming Pools, Spas, and other Water Features Tattooing. Cosmetic Tattooing, Body Piercing, Ear Piercing frailer Courts and Campgrounds GVdt ilfirA cl f)QE$ 9ltufitcturin Establishments Approval Date: 11/ 25/ 13 Effective Date: 10/ 01/ 13 l Montana page P, in 7 ref I i

Medicaid Administration WIC) Nutrition Program Breastfeeding Promotion and Support Farmer's Market WIC% Nutrition j WIC State Plan- WIC WIC Newsletters Women' s& Men' s Reproductive Health Program Family Planning; 1cen Pregnancy Prevention Laboratory Services Bureau Ir Laboratory Services Bureau Environmental and Water Testing Diagnostic Testing Laboratory Emergency Preparedness 1 I- fealth Planning Program Behavioral Risk Factor Surveillance System( BRFSS) Primary Care Program Primary Care Office Training l.init MT Public Health Training Institute Preparedness Program Emergency Preparedness Strategic National Stockpile Operations Services Office of Fair Hearings Providing independent fair hearings for clients and providers participating in DPHHS programs. The Office of Fair Hearings provides impartial administrative hearings for individuals or entities who have been negatively impacted by a program administered by the Department. Hearings officers adjudicate a wide range of department- related issues, including: Eligibility and service issues for public assistance programs( including Medicaid and CHIP); Licensing and certification issues. Ability to pay for care in state institutions; Denial of admission to or discharge from state institutions and long-term care facilities; j Substantiation of' chiid abuse and neglect; Eligibility for vocational rehabilitation services; Enforcement of laws prohibiting sales of tobacco to minors; and Enforcement of the Montana Food, Drug and Cosmetic Act. The Office of Fair Hearings does not havejurisdiction over issues determined by the Child Support Enforcement Division. Hearing officers research statutes, rules, regulations, policies, and court cases to reach conclusions of law. After weighing evidence j and evaluating testimony, they issue written decisions that are binding unless appealed to the state Board of Public Assistance. the Department director, or a district court. Medicaid and CHIP decisions made by the Office of Fair Hearings that are adverse to the applicant or recipient are appealable to the Montana Board of Public Assistance( BPA), which is a quasi judicial board appointed by the Montana Governor and attached to the Department for administrative purposes only. Section 2- 15- 2203, Montana Code Annotated( W.-A.) The BPA functions independently of the department and without approval or control of the department. Section 2- 15- 121. V1CA. i BRA hearing procedure is governed by the Montana Administrative Procedures Act ( MAPA. Title 2, Chapter 4, MCA) and fide 37, Chapter 5 of the administrative rules of Montana. Judicial review by Montana District Courts of BP;A final decision," is as prof Nfe6I1tN1 ilDlt i; MAl6apter T VIC,A. Approval Date: 11/ 25/ 13 Effective Date: 10/ 01/ 13 on ana AI- A6, page Paor* X nt t 3

Ocms Medicaid Administration Business& Financial Services Division( BF SD) The division provides professional services in operational areas critical to the efficient and effective management of the Nlontan r Department of Public Ilealth and Human Services. BFSD also provides leadership and guidance in the development and implementation of accounting policies and procedures and best business practices. BI- SD provides support services for the i department, including: Financial and aCCOUnting oversight. is Cash management, Preparation and filing of federal financial reports, Purchasing;of supplies and equipment, I Payroll processing, Audit coordination Lease mana>ement, ii Mail handling Property management, Records management, Accounts Payable, and Facility reimbursement, Quality Assurance Division (QAD) I The division promotes and protects the health, safety, and well being of people in Montana by providing responsive. independent assessment and monitoring of human services, through respectful relationships. The division fulfills this role by: Licensing and/ or certifying health care, child care, and residential services; Detecting and investigating abuse and fraud committed by recipients of Temporary Assistance to Needy Families( TANF), Medicaid and Food Stamp programs; Monitoring recipient overpayment claims for TANF. Medicaid and SNAP; Performing federally mandated quality-control reviews of the Medicaid and Food Stamp programs; Reducing Medicaid costs by identifying other insurers or parties responsible for paying a beneficiary' s medical expenses; Providing internal and independent audits for DPHHS programs: Conducting retrospective reviews of Medicaid provider claims; Determining medical necessity for prior authorization of medical services and requests for durable medical equipment: Monitoring and evaluating Health Maintenance Organizations for quality assurance arid network adequacy: j Maintaining a certified nurse aide registry; Approving and monitoring nurse aide training programs; Operating the Certificate of Need program; and Ensuring department compliance with the federal Health Information Portability and Accountability Act( HIPAA), l Upload an organizational chart of the Medicaid agency. An attachment is submitted. Provide a description of the structure of the state' s executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies. Iontana I>xecutive Branch The daily administration of the state' s laws, as defined in the Montana Code Annotated, are carried out by the chief executive- the Governor, and his second in command the Lieutenant Governor, the Secretary Of State, the Attorney General, the Superintendent ot" Public Instruction, the State Auditor, and by the staff and employees of the 14 executive branch agenncies. i Acknowledging the importance of providing for an orderly arrangement in the administrative organization of state government. the i number of principal departments from which all executive and administrative offices, boards, bureaus, commissions, agencies and instrumentalitics of the executive branch( except for the office ofgovernor, lieutenant governor, secretary of state, attorney general,. suptN)IMITEtU%0W4Wmic instruction, and auditor) r trpmWaW:tlJdk25t4ective functions, powers, FaWftt Wt0 f3,f4 1ti Ationally Paiy ct of 1 i

Medicaid Administration. 11. 11 umrtec to- not more than 20 p6ricipal departments. Thene on y Department that intersects wit health or uman services, or administrative function related to the business of Medicaid and C1 1111 is the Department of Public I lealth and Human Services. Department of Public I lealth and Iluman Services The largest agency within state government, DPI 11 administrates a wide rang of public assistance programs including: Medicaid, Temporary :Assistance for Needy Families( TANF), food stamps, special supplemental nutrition program for Women. Infants, and Children( WIC), Children' s Health Insurance Plan WI IIP), energy i assistance, child care assistance. Other programs and services provided by the agency include; adoption services, services tor til aging, child support, disability services, drug& alcohol addiction, mental health services and facilities. Oversees the coordination of: a the public health system in Montana through organized efforts to prevent, identify, and counter threats to the health of the public Programs range in scope from nutrition support and I lealth Education. to screening services, to preventive services and surveillance f systenns for infectious and chronic diseases. Entities that deterniirne eligibility outer than the Medicaid Agency( if entities are described tinder Designation and Authority) i_j Remc3ve Type ofentity that determines eligibility: Single state agency under Title 1V- A ( in the 50 states or the District of Columbia) or under Title 1 or XVI (AABD) in Guam. Puerto Rico, or the Virgin Islands C' An Exchange that is a government agency established under sections 131 1( b)( I) or 1321( c)( I) of the Affordable Care Act I' he Federal agency administering the SS1 program provide a description of the staff designated by the entity and the functions they pertbrm in carrN in(, out their responsibility. Pursuant to a 1634 agreement, the Social Security Administration determines Medicaid eligibility for Supplemental Security Income recipients. 11. 11 1111 .. 1111... ......... ........_ ......... ......... ........................................ ..... 1111 _. 111 . 1. ..... .. ......... ......... 1111 Iternove Type of entity that determines eligibility: Single state agency under Title 1V- A ( in the 50 states or the District of Columbia) or under Title I or XVI (,AABD) in Guam. Puerto Rico. or the Virgin Islands e An Fachange that is a government agency established under sections 131 1( b)( 1) or 1321( e)( I) of the Affordable Care .Act C 'the Federal agency administering the SS1 program Provide a description of the staff desi; hated by the entity and the functions they perform in carrying out their responsibility. The Federally- Facilitated Marketplace( FFM) will be determining eligibility for Medicaid for groups of individuals whose income eligibility is determined based on MAGI income methodology and who apply through the FFvI. The FFM will not be assigning an individual who is determined eligible for Medicaid whose income eligibility is determined using MAGI methodology to a specific eligibility group, determining cost-sharing( ifapplicable), or assigning a benefit package- functions that will be performed by the single state agency. 1111 1111__._ 1111.... _-. 12emo e Type of entity that determines eligibility: Single state agency under Title IV-A( in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, N:IK4Tr10-W4@. KMthe Virgin Islands Approval Date: 11/ 25/ 13 Effective Date: 10/01/ 13 Montana Al- A3; page 10_

Medicaid Administration. CAn Exchange that is a government agency established under sections 13 H( b)(]) or 1 121( c)( 1) of the Affordable(- are Act C' I he Federal ram prog agency administering the SSI agency LI Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. The following is a brief description of the organization making eligibility determinations and their responsibilities. Tile organization, the Chippewa Cree Tribe( CCT) of Rocky Boy' s Reservation, will determine Medicaid eligibility on behalf ofthe State for the coverage groups identified. The responsibilities of the designated eligibility staff at tile CCT of Rocky Boy' s Reservation are: A. To make Medicaid eligibility determinations and perform other functions related to the eligibility process to ensure that every effort is made to remove any internal barriers which would delay or prevent a timely eligibility determination for those individuals applying for Medicaid Under the coverage groups specified. B. The function of the CCT is to perform eligibility determinations and re- determinations based on the Medicaid State ['] all, Title XJX Of the Social Security Act, Fille XXI of the Social Security Act. the Medicaid Policy Manual, Montana HII 4521 as codified in the Montana(' ode Annotated, Title 53, Chapter 6, Part 1, and all applicable federal and state rules, regulations arid policies_as amended. CCT shall comply with the provisions in 45 CFR, Part 74( 1998, as amended), 45 CH Part 20.50( 1998, as anlended). of the Code of Federal regulations FR) and all subsequent amendments to these regulations. C. CCT shall make Medicaid eligibility determinations for the following Family Related Medicaid Coverage GrOLIpS: Family ( F,%J Child - t' nder Age 6( 13C), and Child— Age 6- 19( PS). D. The Department is designated as the single stale agency to plan, finance. and Monitor the Medicaid program. The Tribe is designated as a local Public agency for determining and re- determining. on behalf ol"the Department, recipient eligibility 601, individuals applying for Medicaid under the coverage groups identified. C(.-'I' has agreed to accept the oversight authority of the State of Montana and the Department in the administration and supervision of' Medicaid eligibility determination and has accepted authority of the State of' Montana and the Department to all actions taken by the CCT in carrying out its duties. The Department retains ultimate administrative discretion in the administration and supervision of the State Plan, including issuance and interpretation(:)fall applicable policies, rules and regulations, E. CCI has aTribal TAN F' Program. Add Entities that conduct fair hearings other than the Medicaid Agency ( if art described under Designation and Authority) Rerna e I ype of entity that conducts fail- hearings: C An Exchange that is a government agency established Under sections 131 l( b)( 1) or I 321( c)( I) of the Aff'Ordable Care Act Ce' An Exchange appeals entity, including an entity established undLi, section 141 I( f) of the Affordable Care Act Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. ONMEA Will Conduct Medicaid fair hearings for individuals whose Medicaid eligibility has been determined and found ineligible l6r Medicaid by the Federally- facilitated Marketplace( FFM). These Will be individuals whose incorne eligibility is determined based on MAGI income methodology and who applied for health coverage thi-OL12,11 the FFM- ONIEA will receive, populate and route the appeals case file, verify evidence, obtain missing or additional information- determine I validity: render informal resolution decisions: schedule appeals hearings; and issue the hearing officer' s appeal decision. A hearing officer will conduct and review the appeal de novo, and renders a decision based on the evidence from the hearing and the case file,: The hearing officer must be sorneone who has no prior knowledge of the appeal before him or her. TN: MT- 13-0048- MM Approval Date: 11/ 25/ 13 Effective Date: 110/ 01/ 13 Add Moptana A!- A3, page 11 Pare I I of I

Medicaid Administration. I.................................................................................... Supervision of state plan administration by local political subdivisions( if described under Designation and Authority) IS the Supervision ofthe administration done through a state-wide agency which uses local political subdivisions') C Yes ( i, No file types of the local subdivisions that administer the state plan under the supervision of the Medicaid agency are: Counties C' parishes Other Are all ofthe local Subdivisions indicated above used to administer the state plan' Yes s No State Plan Administration A Assuranees 42 CFR ~;31. 10 42 CFR 431. 12 42 CFR 431. 50 Assurances Z The state plan is in operation on a statewide basis, in accordance with all the I' C( lUirenicnts of 42 CFR 431. 50. F All requirements of 42 CFR 431. 10 are met. here is a Medical Care Advisor)/ Committee to the agency director on health and medical services established in accordance with meeting; all the requirements of 42 CFR 431. 11 The Medicaid agency does not delegate, to other than its own officials, the authority to Supervise the plan or to develop or issue policies, rules, and regulations on program matters. Assurance for states that have delegated authority to deter-Inine eligibility: There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431. 10( d). Assurances for states that have delegated authority to conduct fair hearings: There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431. 10( d). When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given I zn FI/ the option to have their fair hearing conducted instead by the Medicaid agency. Assurance for states that have delegated authority to determine eligibility and/ orto conduct fair hearings: 47, The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than FV government agencies which maintain personnel' standards on a merit basis. PRA Disclosure Stateiiient TN: MT- 13- 0048- MM AppirovalDite: 11725TT3 Effective Date: 10/ 01113 Montana Al- A3, page 12 P, w,e 12 of 1

4CMS Medicaid Administration. 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- 11148. The time required to complete this information collection is estimated to average 40 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 comment, concerning the accuracy of the time estimate( s) or suggestions for improving this kmrn, please write to: CMS, 7.500 Security Boulevard, ,Atha: PRA Reports Clearance Officer, Mail Stop C4- 26- 05, Baltimore, Maryland 21244- 1850. TN: MT- 13- 0048- MM Approval Date: 11/ 25/ 13 Effective Date: 10/ 01/ 13 Montana Al- A3, page 13 P, wo, I I of i?

STATE OF MONTANA State Plan Administration Al CERTIFICATION The undersigned, Attorney General of the State of Montana, hereby certifies that the Department of Public Health and Human Services, State of Montana, is the single state agency designated at§ 53- 6- 101, MCA, to administer the Montana Medicaid Program, which implements Title XIX of the United States Social Security Act as a state plan on a statewide basis in Montana, including the authority to make rules and regulations governing the administration of the plan. The state agency' s rules and regulations are binding on the political subdivision of Montana. DATED this day of 2013. TIM FOX Montana Attorney General 11/ 25/ 13 TN 13- 042 Approved Effective Date 1/ 1/ 14 Supercedes 97- 01

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MEDICAID ADMINISTRATION TRANSMITTAL NUMBER: STATE: 13- 0048- MM Montana Notwithstanding the checked assurances on A3, the single state agency has not entered into: 1) an agreement with the Federally- facilitated Marketplace to determine eligibility for Medicaid; nor 2) an agreement with the Office of Marketplace Eligibility Appeals to conduct Medicaid fair hearings to date, but will enter into CMS-approved agreements with the Federally- facilitated Marketplace and the Office of Marketplace Eligibility Appeals as soon as possible and no later than January 1, 2014. FORM HCFA- 179( 07-92)

Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: MT-14- 0004- MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179- like data) 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan (delete if not applicable) TN: MT-14- 0004- MM7 Approval Date: 03/ 06/ 14 Effective Date: 01/ 01/ 14

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 C'( INTEM fOR MEDR ARE&: Nip€M AID SM KB Region VIII March 07, 2013 Mary Dalton, Medicaid& Health Services Manager Montana Department of Health & Human Services 1400 Broadway PO Box 202951 Helena, MT 59620 Re: SPA MT- 14- 0004-MM7 Dear Ms. Dalton: We have reviewed the proposed MAGI State Plan Amendment ( SPA) submitted under transmittal number MT- 14- 0004-MM7. This SPA implements the new provision for MAGI Presumptive Eligibility for Hospitals. Please be informed that this State Plan Amendment was approved March 6, 2014 with an effective date of January 1, 2014. We are enclosing the summary page and the amended plan page( s). Montana should report its PE expenditures on Form CMS-64.9PE and/or Form CMS- 64.9PE Waiver and only select from the ( 2) eligibility drop options, Low Income and/or Family Planning. Additionally prior period adjustments would be reported on the Form CMS- 64.9PEP and/ or the Form CMS- 64.9 PEP Waiver. If you have any questions regarding this SPA please contact Cindy Smith at 303- 844- 7041. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health Operations Cc: Richard Opper, Department Director Duane Preshinger Jo Thompson

MT.0474. R00. 00 - Jan 01, 2014 Page 1 of 2 Medicaid State Plan Eligibility: Sum a v lla e 79 State/Territory name: Montana Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST-YY-0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered. MT- 14- 0004 Proposed Effective Date 01/ 01/ 2014 mm/ dd/ yYYY) Federal Statute/ Regulation Citation 42 CFR 435. 1110 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment Implementation of ACA changes for presumptive eligibility administered by hospitals allowed under the ACA. Hospitals will conduct presumptive for pregnant women; infants and children under age 19; parents and other caretaker relatives; and Former Foster Care Children. Montana will also do presumptive eligibility for Breast and Cervical Cancer Treatment program and our 1115 Waiver program, Plan First. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Single State Agency Signature of State Agency Official Submitted By: Mary Eve Last Revision Date: Feb 28, 2014 Submit Date: Nov 4, 2013 TN: MT- 14- 0004- MM7 Approval Date: 03/ 06/2014 Effective Date: 01/ 01/ 2014 httr):// 157. 199. 113. 99/ MMDL/faces/ protected/ mac/ c01/ print/PrintSelector.i sp 03/ 07/ 2014

Medicaid Eligibility OMB Control Number 0938- 1148 OMB Expiration date: 10/ 31/ 2014 Presumptive Eligibility by Hospitals S21 42 CFR 4-15. 1110 1 lone or more qualified hospitals are determining presumptive eligibility under 42 CFR 435. 1 1 10, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. W Yes No The statee attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: Fm A qualified hospital is a hospital that: Participates as a provider under the Medicaid state plan or a Medicaid 1 1 15 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with stage policies and procedures. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. Assists individuals in completing and submitting, the full application and understanding any documentation requirements. is Yes No The eligibility groups or populations for which hospitals determine eligibility presumptively are: Fm Pregnant Women Infants and Children under Age 19 Parents and Other Caretaker Relatives Adult Group, if covered by the state No Individuals above l33% FPI... under Age 65, if covered by the state Individuals Eligible for Family Planning Services, if covered by the state Former Foster Care Children Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state E] Other Family/ Adult groups: Eligibility groups for individuals age 65 and over 0 Eligibility groups for individuals who are blind F] Eligibility groups for individuals with disabilities F] Other Medicaid state plan eligibility groups Demonstration populations covered under section I 115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. TN: MT- 14- 0004- MM7 Approval Date: 03/ 06/ 2014 Effective Date 01/ 01/ 2014 _ Montana 521, Page 1 Page 1 of 3

Medicaid Eligibility Yes No R The presumptive period begins on the date the determination is made. The end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is tiled by that date. i. Periods of presumptive eligibility are limited as follows: C° No more than one period within a calendar year. C° No more than one period within two calendar years. C No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: Name of limitation Description One period per pregnancy Allow one presumptive period per pregnancy. Allow one presumptive period per calendar year for these groups: Parent/ Caretaker Relative. Infants and One period per calendar Children under age 19, Former Foster Care and Breast& Cervical Cancer Treatment Individuals. The state requires that a written application be signed by the applicant, parent or representative, as appropriate. tr Yes { No C The state uses a single application form for lyledicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility. approved by CMS. A copy of the application farm is included. An attachment is subnfitted. TN. MT- 14- 0004- MM7 Approval Date: 03/ 06/ 2014 Effective Date. 01/ 01/ 2014 Montana 521, Page 2 Pape') of 3

Medicaid Eligibility The presumptive eligibility determination is based on the following factors: The individual' s categorical or non- financial eligibility for the group for which the individual' s presumptive eligibility is if being determined( e. g.. based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1 1 15 demonstration for that group) Household income must not exceed the applicable income standard for the group for which the individual' s presumptive eligibility is being determined, if an income standard is applicable for this group. F State residency Citizenship, status as a national, or satisfactory immigration status I lie state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included. An attachment is submitted. PRA DiSCIOSUI'e 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 40 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. TN: MT- 14- 0004- MM7 Approval Date: 03/ 0612014 Effective Date: 01/ 01/ 2014 Montana S21, Page 3 Pale 3 of 3

Ta 6 Proof of Temporary Coverage for Presumptive Eligibility Dear Provider: The person( s) listed below has temporary health coverage through Presumptive Eligibility (PE). Temporary coverage may last between 30 and 60 days depending on the effective date of coverage shown ( below). To ensure payment, providers must verify eligibility prior to providing services and submitting claims. If you have questions concerning Presumptive Eligibility, please call the Human and Community Services office, 1- 877- 543-7669, ext.2869 OR ext. 3098. Verify Presumptive Eligibility via: Web Portal at www. mtmedicaid. org( click on Montana Access to Health link); FAX Back at 1- 800- 714-0075( do not FAX the completed PE application to this FAX number); or Automated Voice Response at 1- 800-714- 0060 Services included under temporary coverage are the same as those available under regular program coverage. NOTE: Social Security Numbers are requested but are not required._ Social Security Effective Check the appropriate coverage group----] Name Number AND Date Former Parent/ Pregnant Breast& I First- Middle Initial- last) Date of Birth of Coverage HMT Foster Care Caretaker Woman Cervical mm/ dd/ yyyy mm/ dd/ yyyy PCus K ( ages 18 up Relative Cancer to 26) Medicaid i I f I 3 Name of Qualified Entity Determining Presumptive Eligibility ( Please Print) Date Signature of Qualified Entity QUALIFIED ENTITY: Within 5 days of Determination, SCAN PE Application and Proof of Temporary Coverage form, then create a secure ePass account at transfer.mt.eov, and email scanned documents to: HSPresur tine mt, ov— OR FAX same documents to: 1- 877-418-4533. Human and Community Services Division, State of Montana, PO Box 202925, Helena MT 59620-2925 TN: MT- 14-0004- MM7 Approval Date: 03/ 06/2014 Effective Date: 01/ 01/ 2014

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Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: MT-15-0021 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages TN: MT-15-0021 Approval Date: 01/25/2016 Effective Date 01/01/2016

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare& Medicaid Services 1961 Stout Street, Room 08448 Denver, CO 80294 MS CENTERS FOR MEDICARE& MEDICAID SERVICES Region VIII January 25, 2016 Mary Dalton, Medicaid & CHIP Director Montana Department of Public Health & Human Services P.O. Box 4210 Helena, MT 59604 Re: SPA MT- 15- 0021 Dear Ms. Dalton: We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number MT- 15- 0021. This is to add Attachment 4. 19- B " Introduction Page" to the Montana State Plan. Please be informed that this State Plan Amendment was approved today with an effective date of January 1, 2016. We are enclosing the summary page and the amended plan page( s). If you have any questions regarding this SPA please contact Sophia Hinojosa at ( 303) 844- 7129. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations cc: Richard Opper, Department Director Duane Preshinger Jo Thompson Mary Eve Kulawik

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 15- 0021 Montana 3. PROGRAM IDENTIFICATION: Title XIX of the FOR: HEALTH CARE FINANCING ADMINISTRATION Social Security Act( Medicaid) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 01/ 01/ 2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT( Separate Transmittalfor each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: N/A Total FFY 16 ( 9 months) $ 16,611 FFY 17 ( 12 months) $ 22,036 FFY 18 ( 3 months) $ 5, 505 3 Other Laboratory& X-Ray Services FFY 16 ( 9 months) 54 FFY 17 ( 12 months) 72 FFY 18 ( 3 months) 18 5.a Physicians' Services FFY 16 ( 9 months) $ 16, 557 FFY 17 ( 12 months) $ 21, 964 FFY 18 ( 3 months) $ 5, 487 6b Optometrists' Services FFY 16 ( 9 months) 0 FFY 17 ( 12 months) 0 FFY 18 ( 3 months) 0 12. e Hearing Aids FFY 16 ( 9 months) 0 FFY 17 ( 12 months) 0 FFY 18 ( 3 months) 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable): Attachment 4. 19B, Introduction, Pages 1 and 2 of 2 Attachment 4. 19B, Introduction, Pages 1 and 2 of 2 10. SUBJECT OF AMENDMENT: The Attachment 4. 19B Introduction Page is being amended to update the date of fee schedules for services that use Medicare rates or Medicare codes, effective January 1, 2016. 11. GOVERNOR' S REVIEW( Check One): 0 GOVERNOR' S OFFICE REPORTED NO COMMENT X OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED Single Agency Director Review NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: ontana Dept. of Public Health and Human Services jy1 " Mary E. Dalton 13. TYPED NAM : Mary K Dalton State Medicaid Director 14. TITLE: State Medicaid Director Attn: Mary Eve Kulawik 15. DATE SUBMITTED: PO Box 4210 i'-•• ' Helena, MT 59604 FOR REGIONAL OFFICE USE ONLY. 17. DATE RECEIVED:': 18 DATE APPROVED: eer9,2C)1 January 25,,2016 1--/,` PLAN APPROVED ONE COPY ATTACHED:.: ; .. . 19: EFFECTIVE DATE OF APPROVEDIMMATL AL: OFFICIAL: 21 TYPED NAME ARA, MACHO 23: REMARKS: FORM HCFA- 179( 07- 92)

46 Attachment 4. 19B Introduction Page 1 of 2 State Plan under Title XIX of the Social Security Act State/Territory: Montana Dates for Establishing Payment Rates for the following Attachment 4. 19B Services: Effective Dates for Reimbursement Rates for Specified Services: Reimbursement rates for the services listed on this introduction page state plan amendment are effective for services provided on or after that date with two exceptions: 1) Medicaid reimbursement using Medicare rates are updated and effective on the 1st of each quarter based on the Medicare quarterly adjustment. 2) Medicaid reimbursement using Medicare codes are updated and effective on the 10 of each quarter based on the methodology specified in the Attachment 4. 19B, Methods and Standards for Establishing Payment Rates. Payment methods for each service are defined in Attachment 4. 19B, Methods and Standards for Establishing Payment Rates, as referenced. Reimbursement rates/ fee schedules are published on the Department' s website at http:// medicaidprovider.mt.gov. Unless otherwise noted in the referenced state plan, reimbursement rates are the same for both governmental and private providers. Service Attachment Effective Date 3 Other Laboratory& X-Ray Services Attachment 4. 19B, Page 1 January 1, 2016 5a Physicians' Services Attachment 4. 19B, Pages 1 and 2 January 1, 2016 6b Optometrists' Services Attachment 4. 19B, Pages 1 and 2 January 1, 2016 6c Chiropractic Services Attachment 4. 19B, Pages 1 and 2 July 1, 2015 6d Licensed Clinical Social Workers' Services Attachment 4. 19B, Pages 1 and 2 July 1, 2015 6d Licensed Professional Counselors' Services Attachment 4. 19B, Pages 1 and 2 July 1, 2015 6d Licensed Psychologists' Services Attachment 4. 19B, Pages 1 and 2 July 1, 2015 6d Denturist Services Attachment 4. 19B, Pages 1 and 2 July 1, 2015 6d Dental Hygienist Services Attachment 4. 19B, Pages 1 and 2 July 1, 2015 6e Nutritionists' Services Attachment 4. 19B, Page 1 July 1, 2015 7a and 7b Home Health Services Attachment 4. 19B, Page 1 July 1, 2015 7c Durable Medical Equipment and Supplies Attachment 4. 19B, Pages 1 and 2 July 1, 2015 TN: 15- 0021 Approved: 1/ 25/ 16 Effective: 01/ 01/ 16 Supersedes: 15- 0005

State Plan under Title XIX of the Social Security Act State/Territory: Montana Attachment 4.19B Introduction Page 2 of 2 Dates for Establishing Payment Rates for the following Attachment 4.19B Services: (Continued) Service Attachment 7d Home Health Services Attachment 4.198, Page 1 8 Private Duty Nursing Services Attachment 4.198, Page 1 10 Dental Services Attachment 4.198, Pages 1 and 2 l la Physical Therapy Services Attachment 4.198, Pages 1 and 2 llb Occupational Therapy Services Attachment 4.198, Pages 1 and 2 llc Speech Therapy & Audiology Services Attachment 4.198, Pages 1 and 2 12b Denture Services Attachment 4.198, Pages 1 and 2 12c Prosthetic Devices Attachment 4.198, Page 1 12e Hearing Aids Attachment 4.198, Pages 1 and 2 19b Targeted Case Management Services for Adults Attachment 4.198, Page 1 with Severe Disabling Mental Illness (SDMI) 19c Targeted Case Management Services for Individuals with Developmental Disabilities Attachment 4.198, Page 1 Age 16 and Over or who Reside in a DD Children's Group Home 19D Targeted Case Management Services for Youth Attachment 4.198, Page 1 with Serious Emotional Disturbance (SED) 19G Targeted Case Management Services for Attachment 4.198, Page 1 Substance Use Disorders - Youth 19H Targeted Case Management Services for Attachment 4.198, Page 1 Substance Use Disorders - Adult 19i Targeted Case Management Services for Youth with Serious Emotional Disturbance (SED) in an Attachment 4.198, Page 1 Out Of State (OOS) Psychiatric Residential Treatment Facility (PRTF) TN: 15-0021 Supersedes: 15-0005 Approved: 1/25/16 Effective Date July 1, 2015 July 1, 2015 July 1, 2015 July 1, 2015 July 1, 2015 July 1, 2015 July 1, 2015 July 1, 2015 January 1, 2016 July 1, 2015 July 1, 2015 July 1, 2015 July 1, 2015 July 1, 2015 July 1, 2015 Effective: 01/01/16

Table of Contents

State/Territory Name: Montana

State Plan Amendment (SPA) #: = MT-15-0032 This file contains the following documents in the order listed: 1) Approval Letter

2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

TN: MT-15-0032 Approval Date: (2/17/2016 Effective Date = 01/01/2016

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

1961 Stout Street, Room 08-148

Denver, CO 80294

CENTERS FOR MEDICARE & MEDICAID SERVICES

Region VIII

February 19, 2016

Mary Dalton, Medicaid & CHIP Director

Montana Department of Public Health & Human Services P.O. Box 4210

Helena, MT 59604

Re: SPA MT-15-0032 Dear Ms. Dalton:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number MT-15-0032. This SPA adds hospital presumptive eligibility to Montana Medicaid.

Please be informed that this State Plan Amendment was approved on February 17, 2016 with an effective date of January 1, 2016. We are enclosing the summary page and the amended plan

page(s).

If you have any questions regarding this SPA please contact Sophia Hinojosa at (303) 844-7129. Sincerely, /s/

Richard C. Allen Associate Regional Administrator Division for Medicaid & Children’s Health Operations

cc: Richard Opper, Department Director Duane Preshinger Jo Thompson Mary Eve Kulawik

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: Montana

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-15-0032

Proposed Effective Date [01/01/2016 | mm/aa/yyyy)

Federal Statute/Regulation Citation [42 CFR 435.1110

Federal Budget Impact Federal Fiscal Year Amount

First Year $0.00 Second Year 3{0.00 |

Subject of Amendment This SPA adds the newly eligible adult group to the S21, and Montana's PE application and training material.

Governor's Office Review an ® Governor's office reported no comment

(2 Comments of Governor's office received Describe:

© No reply received within 45 days of submittal

© Other, as specified Describe: ; . a

Signature of State Agency Official

Submitted By: Mary Eve Last Revision Date: Dec 16, 2015 Submit Date: Dec 16, 2015

MT-15-0032 Approval Date: 2/17/16 Effective Date: 1/1/16

CCMs. Medicaid Eligibility

State Name:|Montana OMB Control Number: 0938-1148 Transmittal Number: MT - 15 - 0032 Expiration date: 10/31/2014

42 CFR 435.1110

One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision.

@ Yes (No The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: [m] A qualified hospital is a hospital that:

Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of [B] its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures.

Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance {m] with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency.

Assists individuals in completing and submitting the full application and understanding any documentation requirements. @yYes CNo

[MN] The eligibility groups or populations for which hospitals determine eligibility presumptively are: {m] Pregnant Women

Infants and Children under Age 19

Parents and Other Caretaker Relatives

Adult Group, if covered by the state

Individuals above 133% FPL under Age 65, if covered by the state

Individuals Eligible for Family Planning Services, if covered by the state

Former Foster Care Children

Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state

Other Family/Adult groups:

Eligibility groups for individuals age 65 and over

Eligibility groups for individuals who are blind

Eligibility groups for individuals with disabilities

Other Medicaid state plan eligibility groups

OOOOO0Of Bm ee ©

Demonstration populations covered under section 1115

MT-15-0032 Approval Date: 2/17/2016 Effective Date: 1/1/2016 pase | of 3

ccm Medicaid Eligibility

CONF TO kat ae a a A NTN

The state establishes standards for qualified hospitals making presumptive eligibility determinations.

C Yes @No {™] The presumptive period begins on the date the determination is made.

[Mi] The end date of the presumptive period is the earlier of:

The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or

The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

[mM Periods of presumptive eligibility are limited as follows: C No more than one period within a calendar year.

C No more than one period within two calendar years.

@ No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period.

C Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. @ Yes © No

C The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

« The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included.

{m] The presumptive eligibility determination is based on the following factors: The individual's categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is {™@ being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group)

i Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group.

KX] State residency X] Citizenship, status as a national, or satisfactory immigration status

The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included.

MT-15-0032 Approval Date: 2/17/2016 Effective Date: 1/1/2016 Page 2 of 3

Medicaid Eligibility

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 40 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.20140415

MT-15-0032 Approval Date: 2/17/2016 Effective Date: 1/1/2016 pal. 3 of3

Table of Contents

State/Territory Name: Montana

State Plan Amendment (SPA) #: = MT-15-0036

This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

TN: MT-15-0036 Approval Date: 07/19/2016 Effective Date 01/01/2016

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

1961 Stout Street, Room 08-148

Denver, CO 80294

Region VIII

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

July 19, 2016

Ms. Mary E. Dalton

State Medicaid and CHIP Director PO Box 4210

Helena, MT 59601-4210

RE: SPA 15-0036

Dear Ms. Dalton:

We reviewed Montana's proposed State Plan Amendment (SPA) submitted under transmittal number MT-15-0036. This amendment implements federal cost-sharing provisions for Montana’s Medicaid expansion population. Please be informed that this SPA was approved today with an effective date of January 1, 2016. We are enclosing the CMS 179 Form and the approved State Plan pages.

We note that in the SPA review process, we became aware of other issues that we will be addressing separately. We look forward to working with the state to ensure proper implementation of all

requirements.

If you have any questions regarding this SPA, please contact Mary Marchioni at (303) 844-7094.

Sincerely,

_— (

Richard C. Allen

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

cc: Richard Opper, Department Director Duane Preshinger Jo Thompson Mary Eve Kulawik

MT.2384.R00.00 - Jan 01, 2016 Page | of 2

Medicaid Premiums and Cost Sharing: Summary Page (CMS 179)

State/Territory

name:

Montana

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-Y Y-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-15-0036

Proposed Effective Date

01/01/2016 (m/dd/yyyy)

Federal Statute/Regulation Citation

; —

Federal Budget Impact Federal Fiscal Year Amount

First Year [2016 J Second Year |2017 0.00

Subject of Amendment

This state plan amendment implements Montana Medicaid expansion, effective 1/1/16. Its estimated federal * fiscal impact is reported on the MT 15-0025 Summary Page (CMS 179). : yw

Governor's Office Review © Governor's office reported no comment

Comments of Governor's office received Describe:

No reply received within 45 days of submittal Other, as specified Describe:

Signature of State Agency Official Submitted By: Mary Eve

Last Revision . Date Received December 31.3018 /

Date: Date Approved July 19,2018 Signature of Approving Official Jul 13, 2016 Printed Name and Tite ~ 7 Richard C Allen Submit Date: Division of Medheaid and Children's Health Operations Dec 31, 2015

file:///C:/Users/GER6/Desktop/MT%201 5-0036%20A pproval%20Package/HCFA%2017..._ 07/18/2016 MT-15-0036 Approval Date: 7/19/2016 Effective Date: 1/1/2016

£<Ms_ Medicaid Premiums and Cost Sharing

State Name:[Montana | OMB Control Number: 0938-1148

Transmittal Number: MT - 15 - 0036 Expiration date: 10/31/2014

Cost Shating'Requirements °°.” GL, 1916

1916A

42 CFR 447.50 through 447.57 (excluding 447.55)

The state charges cost sharing (deductibles, co-insurance or co-payments) to individuals covered under Medicaid. Yes

The state assures that it administers cost sharing in accordance with sections 1916 and 1916A of the Social Security Act and 42 CFR 447.50 through 447,57.

General Provisions

The cost sharing amounts established by the state for services are always less than the amount the agency pays for the service.

{) No provider may deny services to an eligible individual on account of the individual's inability to pay cost sharing, except as elected by the state in accordance with 42 CFR 447.52(e)(1).

The process used by the state to inform providers whether cost sharing for a specific item or service may be imposed on a ig Pp

beneficiary and whether the provider may require the beneficiary to pay the cost sharing charge, as a condition for receiving

the item or service, is (check all that apply):

[1] The state includes an indicator in the Medicaid Management Information System (MMIS)

(1) The state includes an indicator in the Eligibility and Enrollment System

KX] The state includes an indicator in the Eligibility Verification System

(7) The state includes an indicator on the Medicaid card, which the beneficiary presents to the provider

EX] Other process

Description:

The State of Montana uses provider Medicaid Manuals to show the maximum allowable co-pay amount for services. These can be found on the Montana Medicaid website, medicaidprovider.mt.gov for each provider type. Montana Medicaid providers are not allowed to charge co-pays at point of service until the claim has gone through the adjudication process and been assessed against the individual's 5% household cap. The remittance advice sent to the provider after claims adjudication will indicate whether a co-pay is charged for the service and the amount due from

the member. The State believes this is the only accurate way to keep beneficiaries from being charged above the 5 percent household cap.

The MMIS Verification System will provide information via an online portal and telephone hotline for providers

serving individuals outside of the TPA. The TPA will also have an online portal and telephone hotline for providers serving TPA enrollees.

When beneficiaries are enrolled in Montana Medicaid they receive a member handbook explaining co-pay information including amounts.

Page | of 3 MT-15-0036 Approval Date: 7/19/2016 Effective Date: 1/1/2016

Penementtenin pest pens temesnti

MS = Medicaid Premiums and Cost Sharing

[| Contracts with managed care organizations (MCOs) provide that any cost-sharing charges the MCO imposes on Medicaid enrollees are in accordance with the cost sharing specified in the state plan and the requirements set forth in 42 CFR 447.50 through 447.57.

Cost Sharing for Non-Emergency Services Provided in a Hospital Emergency Department

The state imposes cost sharing for non-emergency services provided in a hospital emergency department. Yes

The state ensures that before providing non-emergency services and imposing cost sharing for such services, that the hospitals providing care:

[Ml] Conduct an appropriate medical screening under 42 CFR 489.24, subpart G to determine that the individual does not need emergency services:

[Ml Inform the individual of the amount of his or her cost sharing obligation for non-emergency services provided in the emergency department:

[Ml Provide the individual with the name and location of an available and accessible alternative non-emergency services provider:

[M Determine that the alternative provider can provide services to the individual in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing if the individual is otherwise exempt from cost sharing; and

[M] Provide a referral to coordinate scheduling for treatment by the alternative provider.

The state assures that it has a process in place to identify hospital emergency department services as non-emergency for purposes of imposing cost sharing. This process does not limit a hospital's obligations for screening and stabilizing treatment of an emergency medical condition under section 1867 of the Act; or modify any obligations under either state or federal standards relating to the application of a prudent-layperson standard for payment or coverage of emergency medical services by any managed care organization.

The process for identifying emergency department services as non-emergency for purposes of imposing cost sharing is:

Hospitals are required to comply with federal requirements to screen for and provide services to individuals who require emergency care. The State presumes all visits to the emergency department are not subject to cost sharing, unless the provider provides a written attestation to the State that the provider meets the State’s requirements for imposing cost- sharing for non-emergency department services. Specifically, the State will require that a hospital may determine a visit to the emergency department to be a non-emergency and subject the member to a co-payment only if the hospital has a process in place to: (1) screen for and assess whether the visit is a non-emergeny, as required under federal law; (2) provide the individual with the name and location of an alternative non-emergency service provider; (3) determine that the alternative provider can provide services at a lower cost sharing amount; and, (4) provide a referral to schedule treatment by the alternative provider. In the event a visit is determined to be a non-emergency, the hospital may bill the patient once the claim is adjudicated. The State will instruct hospitals of these requirements, establish a hospital attestation process, and inform beneficiaries that they may only be charged a co-payment for non-emergency use of the ER if these conditions are met.

Cost Sharing for Drugs

The state charges cost sharing for drugs. Yes

The state has established differential cost sharing for preferred and non-preferred drugs. Yes

[lM] The state identifies which drugs are considered to be non-preferred.

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CMS Medicaid Premiums and Cost Sharing

The state assures that it has a timely process in place to limit cost sharing to the amount imposed for a preferred drug in the case of a non-preferred drug within a therapeutically equivalent or similar class of drugs, if the individual's prescribing provider determines that a preferred drug for treatment of the same condition either will be less effective for the individual, will have adverse effects for the individual, or both. In such cases, reimbursement to the pharmacy is based on the appropriate cost sharing amount.

Beneficiary and Public Notice Requirements

Consistent with 42 CFR 447.47. the state makes available a public schedule describing current cost sharing requirements in a manner that ensures that affected applicants. beneficiaries and providers are likely to have access to the notice. Prior to submitting a SPA which establishes or substantially modifies existing cost sharing amounts or policies, the state provides the public with advance notice of the SPA. specifying the amount of cost sharing and who is subject to the charges, and provides reasonable opportunity for stakeholder comment. Documentation demonstrating that the notice requirements have been met are submitted with the SPA. The state also provides opportunity for additional public notice if cost sharing is substantially modified during the SPA approval process.

Other Relevant Information

Montana has notified the public and provided opportunities for public input on cost sharing requirements through its website as well as the 1115 Waiver public notice process. Montana has taken the following public notice actions: respective dates are noted next to each action.

1. Published Montana Administrative Register 37-730 (October 29, 2015)

2. Published public notice in newspapers in three of Montana’s largest communities (November 22, 2015)

3. Posted public notice on the DPHHS website (November 19, 2015)

4. Sent an informational memo to the Montana Health Coalition (State’s medical advisory committee) members, ad hoc members, and interested parties and posted the memo to the DPHHS website (November 18, 2015)

5. Hosted a public meeting and webinar to collect input on the Basic Medicaid Waiver (December 2, 2015)

6. Presented and discussed the transition and Basic Medicaid Waiver in public mectings/forums that included the opportunity for public comment, including: (1) HELP Act legislative public hearings in both the Montana Senate and House lof Representatives (March and April 2015); (2) In-person tribal consultations with the State's tribal governments, tribal health programs, Urban Indian Centers, and the Indian Health Service in Helena, Montana (August 2015); (3) National Alliance for Mental IlIness statewide conference in Billings, Montana (October 2015); (4) Meeting of Mental Health Center Directors in Helena, Montana (November 2015); (5) Legislative Interim Children, Families, Health, and Human Services Committee in Billings, Montana (November 2015); and Weekly meetings between the Governor's Office and stakeholders (ongoing).

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 40 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.20140418

Page 3 of 3 MT-15-0036 Approval Date: 7/19/2016 Effective Date: 1/1/2016

CCMS = Medicaid Premiums and Cost Sharing

State Name:|Montana | OMB Control Number: 0938-1148 Transmittal Number: MT - 15 - 0036 Expiration date: 10/31/2014

1916 1916A 42 CFR 447.52 through 54 The state charges cost sharing to all categorically needy (Mandatory Coverage and Options for Coverage) individuals. Yes Services or Items with the Same Cost Sharing Amount for All Incomes Dollars or Service or Item Amount |Percentage’ Unit Explanation >} {npatient Hospital 75.00 Ig Entire Stay x | Pharmacy 4.00 The charge can be $1.00 up to $4.00 per script with a : Lae $ Prescription $24.00 per month cap. This copayment is subject to x , change 6/1/16. oath Ambulatory Surgical 4.00 | wy + Center 5 . S_ Visit x sf | Denturists 4.00 $ [visi xX “| Durable Medical 4.00 .. +: + Equipment s | Visit x Federally Qualified 4.00 pit , + Health Center 8 Visit x sf | Dialysis Clinics 4.00 [5 [visi x af | Outpatient Hospital 4.00 ig | Visit x a | Rural Health Clinic 4.00 [fg Visit x Home Infusion 4.00 & af | Therapy (codes 99602 $ Visit x and 99601 are exempt) * | Independent 4.00 a + Diagnostic Testing $ Visit x Facilities Mid-Level 4.00 Le + Practitioners $ Visit x af | Physician 4.00 |l¢ Visit x + Podiatry 4.00 ig Visit X ‘gp | Psychiatrists 4.005 [Visit x af | Dental 3.00 ig Visit This copayment is subject to change 6/1/16. X se Home Health 3.00 [s Visit This copayment is subject to change 6/1/16. xX Page | of 3

MT-15-0036 Approval Date: 7/19/2016 Effective Date: 1/1/2016

Oe

ccmMs Medicaid Premiums and Cost Sharing

Dollars or Service or Item Amount Percentage} Unit Explanation + Licensed Professional 3.00 $ Visi This copayment is subject to change 6/1/16. "4 Counselors 'sit 4 af | Psychological Services 3.00 Ig [visi This copayment is subject to change 6/1/16. x af | Social Worker 3.00 Ig Visit This copayment is subject to change 6/1/16. xX af | Speech Therapy 3.00 lig Visit This copayment is subject to change 6/1/16. x a Audiology 2.00 ig ‘| Visit This copayment is subject to change 6/1/16. x + Hearing Aids 2.00 $ visit This copayment is subject to change 6/1/16. xX of | Occupational Therapy 2.00 1g Visit This copayment is subject to change 6/1/16. x + Opticians 2.00 |Ig Visit | This copayment is subject to change 6/1/16. xX + Optometric 2.00 Ig [vse This copayment is subject to change 6/1/16. %K sf | Physical Therapy 2.00 Ig [visi This copayment is subject to change 6/1/16. x | Public Health Clinics 1.0015 I visit This copayment is subject to change 6/1/16. xX Services or Items with Cost Sharing Amounts that Vary by Income Service or Item: Indicate the income ranges by which the cost sharing amount for this service or item varies. Incomes Incomes Less Dollars or Greater than |than or Equal to} Amount {Percentage Unit Explanation + $ |[visi x Add Service or Item

Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals

If the state charges cost sharing for non-preferred drugs (entered above), answer the following question:

The state charges cost sharing for non-preferred drugs to otherwise exempt individuals. No

Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department Charged to Otherwise Exempt Individuals

If the state charges cost sharing for non-emergency services provided in the hospital emergency department (entered above), answer the following question:

The state charges cost sharing for non-emergency services provided in the hospital emergency department to otherwise exempt individuals. No Page 2 of 3

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coms Medicaid Premiums and Cost Sharing

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 40 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 20140415

Page 3 of 3 MT-15-0036 Approval Date: 7/19/2016 Effective Date: 1/1/2016

Cems Medicaid Premiums and Cost Sharing

State Name:[Montana OMB Control Number: 0938-1148 Transmittal Number: MT - 15 - 0036 Expiration date: 10/31/2014 Cost Sharing Amounts + ody Thdividualo -2~' G2] 1916

I916A

42 CFR 447.52 through 54

The state charges cost sharing to all medically needy individuals. Yes

The cost sharing charged to medically needy individuals is the same as that charged to categorically needy individuals. Yes

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 40 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 20140415

Page | of | MT-15-0036 Approval Date: 7/19/2016 Effective Date: 1/1/2016

Cres PO sane Aae erie ate Un

State Name:[Montana

Transmittal Number: MT - 15 - 0036

Medicaid Premiums and Cost Sharing

OMB Control Number: 0938-1148

Expiration date: 10/31/2014

1916 1916A 42 CFR 447.52 through 54

The state targets cost sharing to a specific group or groups of individuals.

Yes

Population Name (optional): |

Eligibility Group(s) Included: [Adults aged 19-64 in Montana who have incomes between 51% FPL and 138% FPL

Incomes Greater than 0% FPL} TO Incomes Less than or Equal to 138% FPL

Specialist

Dollars or Service Amount [Percentage Unit Explanation + Inpatient Hospital 10.00], : Members 101% - 138% FPL. 10% of the x % Entire Stay payment the State makes for the service. + Inpatient Hospital 75.00 $ | [Entire Stay Members 0- 100% FPL. 4 + Durable Medical Equipment 10.00/[, Members 101% - 138% FPL. 10% of the X % Item payment the State makes for the service. + Durable Medical Equipment 4.00 S| [item Members 0 - 100% FPL. X Lab/Radiology 10.00 Members 101% - 138% FPL. 10% of the + : % Procedure payment the State makes for the service. x + Lab/Radiology 4.00 $ Procedure Members 0 - 100% FPL. xX Primary Care Physician 10.00 Members 101% - 138% FPL. 10% of the payment the State makes for the service. + ° a Services that are considered preventive xX % Visit services and therefore exempt from copayments are outlined in the 1115 Waiver and Preventive Services Protocol. Primary Care Physician 4.00 Members 0 - 100% FPL. Services that are considered preventive + $ Visit services and therefore exempt from x copayments are outlined in the 1115 Waiver and Preventive Services Protocol. Outpatient Hospital 10.00 6 -_ Members 101% - 138% FPL. 10% of the % Visit payment the State makes for the service. Outpatient Hospital 4.00 $ Visit Members 0 - 100% FPL.

10.00 |v . % Visit

Specialist

+) +) +) +

Members 101% - 138% FPL. 10% of the payment the State makes for the service.

4.00f, [Visi

Members 0 - 100% FPL.

mS | MS |< | OK

MT-15-0036

Approval Date: 7/19/2016

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coms Medicaid Premiums and Cost Sharing

Dollars or Service Amount {Percentage Unit Explanation + Mid-Level Practitioner 10.00 le Visit Members 101% - 138% FPL. 10% of the x ° ‘sl ayment the State makes for the service. — I + Mid-Level Practitioner 4.00 5 [visit | Members 0 - 100% FPL. x Psychiatrist 10.00 a Members 101% - 138% FPL. 10% of the + % Visit payment the State makes for the service. x + Psychiatrist 4.00 [s Visit Members 0 - 100% FPL. x + Behavioral Health Provider 10.00], Visi Members 101% - 138% FPL. 10% of the 4 % isit payment the State makes for the service. ~ + Behavioral Health Provider 4.00 $ [visit Members 0 - 100% FPL. xX + Other Medical Professional 10.00 5 _ Members 101% - 138% FPL. 10% of the x % Visit payment the State makes for the service. Ry + Other Medical Professional 4.00) $ Visit Members 0 - 100% FPL. xX Denturists 10.00 a Members 101% - 138% FPL. 10% of the + % | Visit payment the State makes for the service. x + Denturists 4.00 5 [[visi Members 0 - 100% FPL. X Federally Qualified Health Center 10.00 _. Members 101% - 138% FPL. 10% of the p + % Visit payment the State makes for the service. x + Federally Qualified Health Center 4.00) $ [Visit Members 0 - 100% FPL. X Rural Health Clinic 10.00 ve Members 101% - 138% FPL. 10% of the rs + % Visit payment the State makes for the service. x + Rural Health Clinic 4.00 $ I[ visit Members 0 - 100% FPL. x Dialysis Clinic 10.00 a Members 101% - 138% FPL. 10% of the . + % Visit payment the State makes for the service. x >} Dialysis Clinic 4.00 $ ic Members 0 - 100% FPL. xX Ambulatory Surgical Center 10.00 a Members 101% - 138% FPL. 10% of the + % Visit payment the State makes for the service. x Ambulatory Surgical Center 4.00 we Members 0 - 100% FPL. + $ Visit x + Independent Diagnostic Testing 10.00 0% Visi Members 101% - 138% FPL. 10% of the 4 Facility ° [vist payment the State makes for the service. y! + Independent Diagnostic Testing 4.00 $ Visit Members 0 - 100% FPL. x Facility {sl + Podiatry 10.00) » [vi . Members 101% - 138% FPL. 10% of the X ° 'sit payment the State makes for the service. ‘ + Podiatry 4.00 5 Visit Members 0 - 100% FPL. xX + Home Infusion Therapy (codes 10.00 % [vi Members 101% - 138% FPL. 10% of the x 99601 and 99602 are exempt) ° 'sit payment the State makes for the service.

Home Infusion Therapy (codes 4.00 a Members 0 - 100% FPL. . Fl59601 and 99602 are exempt) $ Visit x Non-Emergency Use of the ER 8.00 Individuals with income 51-138% of the FPL

hose services are being administered by the + $ Visit he 8 yine hy ° TPA.

MT-15-0036

Approval Date: 7/19/2016

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S$. Medicaid Premiums and Cost Sharing

‘Cimon PO RNC Ae aneCINr AAR ICE

Dollars or Service Amount [Percentage Unit Explanation Pharmacy 4.00 For preferred brands. Pharmacy drugs that are considered preventive services and therefore + $ Prescription are exempt from copayments are outlined in > 4 the 1115 Waiver and Preventive Services Protocol. Pharmacy 8.00 For non-preferred. Pharmacy drugs that are considered preventive services and therefore + $ Prescription are exempt from copayments are outlined in xX the 1115 Waiver and Preventive Services Protocol.

The state permits providers to require individuals to pay cost sharing as a condition for receiving items or services, subject to the conditions specified at 42 CFR 447.52(e)(1). This is only permitted for non-exempt individuals with family income above] No 100% FPL.

Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals

If the state targets cost sharing for non-preferred drugs to specific groups of individuals (entered above), answer the following question:

The state charges cost sharing for non-preferred drugs to otherwise exempt individuals. No

Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department Charged to Otherwise Exempt Individuals

If the state charges cost sharing for non-emergency services provided in the hospital emergency department to specific individuals (entered above). answer the following question:

The state charges cost sharing for non-emergency services provided in the hospital emergency department to otherwise No

exempt individuals. Remove Population

Add Population

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 contro] number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 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 20140415

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a | ccms Medicaid Premiums and Cost Sharing

State Name:|Montana | OMB Control Number: 0938-1148

Transmittal Number: MT - 15 - 0036 Expiration date: 10/31/2014

sR

42 CFR 447.56 1916 1916A

The state administers cost sharing in accordance with the limitations described at 42 CFR 447.56, and 1916(a)(2) and (j) and 1916A(b) of the Social Security Act, as follows:

Exemptions

Groups of Individuals - Mandatory Exemptions The state may not impose cost sharing upon the following groups of individuals:

[lM] Individuals ages | and older, and under age 18 eligible under the Infants and Children under Age [8 eligibility group (42 CFR 435.118).

[im] Infants under age | eligible under the Infants and Children under Age 18 eligibility group (42 CFR 435.118), whose income does not exceed the higher of:

[M 133% FPL; and

[im If applicable, the percent FPL described in section 1902(1)(2)(A){iv) of the Act. up to 185 percent. [M] Disabled or blind individuals under age 18 eligible for the following eligibility groups:

[M) SSI Beneficiaries (42 CFR 435.120).

[@] Blind and Disabled Individuals in 209(b) States (42 CFR 435.121).

[iM] Individuals Receiving Mandatory State Supplements (42 CFR 435.130).

[lM] Children for whom child welfare services are made available under Part B of title IV of the Act on the basis of being a child in foster care and individuals receiving benefits under Part E of that title, without regard to age.

[M] Disabled children eligible for Medicaid under the Family Opportunity Act (1902(a)(10)(A)(ii)(XTX) and 1902(cc) of the Act).

[i] Pregnant women, during pregnancy and through the postpartum period which begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of pregnancy ends, except for cost sharing for services specified in the state plan as not pregnancy-related.

Any individual whose medical assistance for services furnished in an institution is reduced by amounts reflecting available income other than required for personal needs.

An individual receiving hospice care, as defined in section 1905(o) of the Act.

Indians who are currently receiving or have ever received an item or service furnished by an Indian health care provider or through referral under contract health services.

» @m @

Individuals who are receiving Medicaid because of the state's election to extend coverage to the Certain Individuals Needing Treatment for Breast or Cervical Cancer eligibility group (42 CFR 435.213).

Page | of 5 MT-15-0036 Approval Date: 7/19/2016 Effective Date: 1/1/2016

<€MS. Medicaid Premiums and Cost Sharing

Groups of Individuals - Optional Exemptions

The state may elect to exempt the following groups of individuals from cost sharing:

The state elects to exempt individuals under age 19, 20 or 21, or any reasonable category of individuals 18 years of age Yes or over.

Indicate below the age of the exemption: C Under age 19 C Under age 20 @ Under age 2!

C Other reasonable category

The state elects to exempt individuals whose medical assistance for services furnished in a home and community-based Yes setting is reduced by amounts reflecting available income other than required for personal needs.

Services - Mandatory Exemptions

The state may not impose cost sharing for the following services:

[fm] Emergency services as defined at section 1932(b)(2) of the Act and 42 CFR 438.1 14(a).

[™] Family planning services and supplies described in section 1905(a)(4)(C) of the Act, including contraceptives and

pharmaceuticals for which the state claims or could claim federal match at the enhanced rate under section 1903(a)(5) of the Act for family planning services and supplies.

[M] Preventive services, at a minimum the services specified at 42 CFR 457.520, provided to children under 18 years of age regardless of family income, which reflect the well-baby and well child care and immunizations in the Bright Futures guidelines issued by the American Academy of Pediatrics.

[M] Pregnancy-related services, including those defined at 42 CFR 440.210(a)(2) and 440.250(p), and counseling and drugs for cessation of tobacco use. All services provided to pregnant women will be considered pregnancy-related, except those services specificially identified in the state plan as not being related to pregnancy.

{) Provider-preventable services as defined in 42 CFR 447.26(b).

Enforceability of Exemptions

The procedures for implementing and enforcing the exemptions from cost sharing contained in 42 CFR 447.56 are (check all that apply):

[B] To identify that American Indians/Alaskan Natives (AI/AN) are currently receiving or have ever received an item or service

furnished by an Indian health care provider or through referral under contract health services in accordance with 42 CFR 447.56(a)(1)(x), the state uses the following procedures:

The state accepts self-attestation [5 The state runs periodic claims reviews [EX] The state obtains an Active or Previous User Letter or other Indian Health Services (IHS) document

KX] The Eligibility and Enrollment and MMIS systems flag exempt recipients

Page 2 of § MT-15-0036 Approval Date: 7/19/2016 Effective Date: 1/1/2016

SRMAS Medicaid Premiums and Cost Sharing

[ Other procedure

Additional description of procedures used is provided below (optional):

The State accepts self-attestation in response to the question on the single streamlined application inquiring whether the applicant has ever received an item or a service from an I/T/U.

{M] To identify all other individuals exempt from cost sharing, the state uses the following procedures (check all that apply):

[xX] The MMIS system flags recipients who are exempt

[] The Eligibility and Enrollment System flags recipients who are exempt [1] The Medicaid card indicates if beneficiary is exempt

The Eligibility Verification System notifies providers when a beneficiary is exempt

[2] Other procedure

Additional description of procedures used is provided below (optional):

Cost sharing tracking against the 5% household cap will apply to both premiums and co-payments. When the participant

pays their premium, the payment is applied to the aggregate household cap during the quarter for which the premium is due.

Payments to Providers

The state reduces the payment it makes to a provider by the amount of a beneficiary's cost sharing obligation, regardless of whether the provider has collected the payment or waived the cost sharing, except as provided under 42 CFR 447.56(c).

[Payments to Managed Care Organizations

The state contracts with one or more managed care organizations to deliver services under Medicaid.

Aggregate Limits

Medicaid premiums and cost sharing incurred by all individuals in the Medicaid household do not exceed an aggregate limit of 5 percent of the family's income applied on a quarterly or monthly basis.

[M] The percentage of family income used for the aggregate limit is:

© 5% C 4% C 3% C 2% C 1%

C Other: %

[lM] The state calculates family income for the purpose of the aggregate limit on the following basis:

Page 3 of 5 MT-15-0036 Approval Date: 7/19/2016 Effective Date: 1/1/2016

Medicaid Premiums and Cost Sharing

COTS POE SATIRE Ka 8 eR aM NN

@ Quarterly

C Monthly

The state has a process to track each family's incurred premiums and cost sharing through a mechanism that does not

. . Yes rely on beneficiary documentation.

[) Describe the mechanism by which the state tracks each family's incurred premiums and cost sharing (check all that apply):

[X As claims are submitted for dates of services within the family's current monthly or quarterly cap period, the state applies the incurred cost sharing for that service to the family's aggregate limit. Once the family reaches the aggregate limit, based on incurred cost sharing and any applicable premiums, the state notifies the family and providers that the family has reached their aggregate limit for the current monthly or quarterly cap period, and are no longer subject to premiums or cost sharing.

(2) Managed care organization(s) track each family's incurred cost sharing, as follows:

RR) Other process:

The State utilizes an electronic data sharing program that evaluates whether the individual is subject to premiums. and co-payments or exempt, whether the service is exempt from a co-payment, and whether the individual has hit the 5% aggregate household cost sharing cap. On a daily basis, payer systems MMIS, TPA and Pharmacy Benefit Manager (PBM)—send the electronic data sharing program processed claims. On a daily basis, the electronic data sharing program will send updated cost sharing balances to the MMIS, TPA and PBM. The provider is notified through a remittance advice of the applicable co-payment and the provider will bill the beneficiary.

[HH Describe how the state informs beneficiaries and providers of the beneficiaries’ aggregate family limit and notifies beneficiaries and providers when a beneficiary has incurred premiums and cost sharing up to the aggregate family limit and individual family members are no longer subject to premiums or cost sharing for the remainder of the family's current monthly or quarterly cap period:

The State will issue a written notice to a beneficiary when the beneficiary reaches their aggregate household cap. Once the maximum aggregate limit is reached the Electronic Data Exchange (EDX) system will notify the State and a letter will be issued that no further co-pay will be taken in that quarter. This functionality will be in place July Ist, 2016.

Consumers may access information regarding the aggregate household limit through the following avenues: (1) a TPA hotline for TPA enrollees; or (2) an MMIS hotline or online consumer portal for non-TPA enrollees.

The state has a documented appeals process for families that believe they have incurred premiums or cost sharing over

the aggregate limit for the current monthly or quarterly cap period. Yes

Describe the appeals process used:

The member will use the standard fair hearing process if they disagree with a decision on the aggregate limit. To request a fair hearing the member may call the Office of Fair Hearings or submit a form with their complaint to the office. The fair hearing process is documented in ARM 37.5.307.

{) Describe the process used to reimburse beneficiaries and/or providers if the family is identified as paying over the aggregate limit for the month/quarter:

The claim will be reprocessed to indicate no co-pay. The provider is responsible to reimburse the member for any co-pay that was collected in error. When the State sends a notice to the beneficiary that they hit the 5% cap, the notice will also include information that they may have been overcharged by their provider and they should reach out to the provider to

Page 4 of 5 MT-15-0036 Approval Date: 7/19/2016 Effective Date: 1/1/2016

S Medicaid Premiums and Cost Sharing

(Coser HOE searing Ae Sapp ARS END

[seek reimbursement. |

[] Describe the process for beneficiaries to request a reassessment of their family aggregate limit if they have a change in circumstances or if they are being terminated for failure to pay a premium:

Beneficiaries will contact the Office of Public Assistance (OPA) and follow the process outlined by OPA.

The state imposes additional aggregate limits, consistent with 42 CFR 447.56(f)(5). Yes

Description of additional aggregate limits:

Pharmacy benefits currently have a monthly cap for members that are under 50% FPL and fall into the non-TPA expansion and Standard Medicaid population. The monthly cap is $24.00.

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 40 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 20140415

Page 5 of 5 MT-15-0036 Approval Date: 7/19/2016 Effective Date: 1/1/2016

TableofContents State/TerritoryName: Montana StatePlanAmendment (SPA) #: MT-16-0003 Thisfilecontainsthefollowingdocumentsintheorderlisted: 1) ApprovalLetter 2) CMS179Form/SummaryForm (with179-likedata) 3) ApprovedSPAPages TN: ApprovalDate: EffectiveDate MT-16-000305/24/201601/01/2016

DEPARTMENT OF HEALTH& HUMAN SERVICESms Centers for Medicare& Medicaid Services 1961 Stout Street, Room 08- 148 Denver, CO 80294 CENTERS FOR MEDICARE&. MEDICAID SERVICES Region VIII May 24, 2016 Mary Dalton, Medicaid & CHIP Director Montana Department of Public Health & Human Services P. O. Box 4210 Helena, MT 59604 Re: SPA MT- 16- 0003 Dear Ms. Dalton: We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number MT- 16- 0003. This amendment is to add the new expansion adults to the State Plan. Please be informed that this State Plan Amendment was approved May 24, 2016, with an effective date of January 1, 2016. We are enclosing the summary page and the amended plan page( s). If you have any questions regarding this SPA please contact Michelle Baldi at ( 312) 3353- 0909. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations cc: Richard Opper, Department Director Duane Preshinger Jo Thompson Mary Eve Kulawik

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938- 0193_ TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 16- 0003 Montana FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE _. SOCIAL SECURITY ACT( MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 01/ 01/ 2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT( Separate Transmittalfor each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: j 7. FEDERAL BUDGET IMPACT: 1932( a) a. FFY 2016( 9 mos): $ 21, 599 b. FFY 2017( 12 mos): $ 38, 505 c. FFY 2018( 3 mos): $ 10,435 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable): Attachment 3. 1- F, Pages 1- 11 Attachment 3. 1- F, Pages 1- 11 10. SUBJECT OF AMENDMENT: The purpose of this amendment is to add the expansion population to the State Plan. The update is necessary to include these new adults that are exempt from Third Party Administrator( TPA) enrollment, such as medically frail and those who require continuity of coverage that is not available or could not be effectively delivered through the TPA. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED Single Agency Director Review NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Mary E. Dalton 13. TYPED NAME: Mary E. Dalton Attn: Mary Eve Kulawik PO Box 4210 14. TITLE: State Medicaid Director Helena MT 59620 15. DATE SUBMITTED: FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 3/23/ 2016 IS. DATE APPROVED: 5/2412016 PLAN APPROVED- ONE COPY: ACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: OFFICIAL: 1/ 1/ 2016 21. TYPED NAME: Richard C. Allen ITLE: Associate Regional Administrator, DMCHO 23. REMARKS: FORM HCFA- 179( 07- 92)

CMS-PM-10120 ATTACHMENT3.1-F Page1 OMBNo.:0938-0933 State: MONTANA Citation ConditionorRequirement 1932(a)(1)(A) A. Section1932(a)(1)(A) oftheSocialSecurityAct. TheStateofMontanaenrollsMedicaidbeneficiariesonamandatorybasisinto managedcareentities (managedcareorganization (MCOs) and/orprimarycarecase managers (PCCMs)) intheabsenceofsection1115orsection1915(b) waiver authority. Thisauthorityisgrantedundersection1932(a)(1)(A) oftheSocial SecurityAct (theAct). Underthisauthority, astatecanamenditsMedicaidstate plantorequirecertaincategoriesofMedicaidbeneficiariestoenrollinmanaged careentitieswithoutbeingoutofcompliancewithprovisionsofsection1902ofthe Actonstatewideness (42CFR431.50), freedomofchoice (42CFR431.51) or comparability (42CFR440.230). ThisauthoritymaynotbeusedtomandateenrollmentinPrepaidInpatientHealth Plans (PIHPs), PrepaidAmbulatoryHealthPlans (PAHPs), norcanitbeusedto mandatetheenrollmentofMedicaidbeneficiariesdescribedin42CFR438.50(d). Wherethestate’sassuranceisrequestedinthisdocumentforcompliancewitha particularrequirementof42CFR438etseq., thestateshallplacecheckmarkto affirmsuchcompliance. 1932(a)(1)(B)(i) B. ManagedCareDeliverySystem.1932(a)(1)(B)(ii) 42CFR438.50(b)(1)-(2) TheStatewillcontractwiththeentity(ies) belowandreimbursethemasnoted undereachentitytype. 1. MCO a. Capitation 2. PCCM (individualpractitioners) a. Casemanagementfee b. Bonus/incentivepayments c. Other (pleaseexplainbelow) PatientCenteredMedicalHome (PCMH) providerswillbereimbursedapermember permonthcapitationfeeinadditiontoMedicaidfee-for-servicereimbursement, throughoneofthreepermemberpermonthpaymentsforeachenrolledMontana MedicaidPatientCenteredMedicalHome (MTMPCMH) member: a. apreventiveandparticipationperMTMPCMHmemberpermonthfeefor memberswithnochronicconditions; or b. asinglechronic disease managementperMTMPCMHmemberper monthfeeformemberswithhypertension, asthma, ordepression; or c. achronicdiseasemanagementperMTMPCMHmemberpermonthfeefor memberswithdiabetes, ischemicvasculardisease (IVD), ormultiple chronicdiseasesfromb. TN: 16-0003 ApprovalDate: 5/24/16 EffectiveDate: 1/1/2016 SupersedesTN: 14-0041

CMS-PM-10120 ATTACHMENT3.1-F Page2 OMBNo.:0938-0933 State: MONTANA Citation ConditionorRequirement 3. PCCM (entitybased) a. Casemanagementfee b. Bonus/incentivepayments c. Other (pleaseexplainbelow) PCMHproviderswillbereimbursedapermemberpermonthcapitationfeein additiontoMedicaidfee-for-servicereimbursement, throughoneofthreeper memberpermonthpaymentsforeachenrolledMTMPCMHmember: a. apreventiveandparticipationperMTMPCMHmemberpermonthfee formemberswithnochronicconditions; or b. asinglechronic disease managementperMTMPCMHmemberper monthfeeformemberswithhypertension, asthma, ordepression; or c. achronicdiseasemanagementperMTMPCMHmemberpermonthfeefor memberswithdiabetes, IVD, ormultiplechronicdiseasesfromb. ForstatesthatelecttopayaPCCMabonus/incentivepaymentasindicatedin B.2.b. orB.3.b, placeacheckmarktoaffirmthestatehasmetallofthe followingconditions (whicharerepresentativeof theriskincentiverulesfor managedcarecontractspublishedin42CFR438.6(c)(5)(iv)). a. IncentivepaymentstothePCCMwillnotexceed5% ofthetotal FFSpaymentsforthoseservicesprovidedorauthorizedbythe PCCMfortheperiodcovered. b. Incentiveswillbebaseduponafixedperiodoftime. c. Incentiveswillnotberenewedautomatically. d. Incentiveswillbemadeavailabletobothpublicandprivate PCCMs. e. Incentiveswillnotbeconditionedonintergovernmental transferagreements. f. Incentiveswillbebaseduponspecificactivitiesandtargets. TN: 16-0003 ApprovalDate: 5/24/16 EffectiveDate: 1/1/2016 SupersedesTN: 14-0041

CMS-PM-10120 ATTACHMENT3.1-F Page3 OMBNo.:0938-0933 State: MONTANA Citation ConditionorRequirement CFR438.50(b)(4) C. PublicProcess. Describethepublicprocessincludingtribalconsultation, ifapplicable, utilizedfor boththedesignoftheprogramanditsinitialimplementation. Inaddition, describe whatmethodsthestatewillusetoensureongoingpublicinvolvementoncethestate planprogramhasbeenimplemented. (Example: publicmeeting, advisorygroups.) MTMPCMHdevelopmentandimplementationprocess: TheDepartmenthasbeen involvedwithaPCMHmulti-payerstakeholdergroup, theMontanaPCMH StakeholderCouncil, establishedinMontanain2009bytheCommissionerof SecuritiesandInsurance. Thepurposeofthegroupistodevelopamulti-payer initiativedrivenbyanimprovementplanfocusedonfivecoreelements: 1. Developingkeypartnerships 2. Definingandrecognizingmedicalhomes3. Improvingpurchasingandreimbursementpolicies; 4. Supportingpracticechange and 5. Measuringprogress. TheCounciliscomprisedofprimarycareproviders, specialtyproviders, publicand privatepayers, consumers, advocates, andrepresentativesofproviderandadvocate associations. MeetingsarealsoattendedbyStateLegislators, legislativestaff, and membersofthegeneralpublic. ThisCouncilwascodifiedduringthe2013 LegislativeSessionandcontinuestoserveastheadvisorycouncilforMedicaid’s PCMHinitiative. MedicaidreliesonthePCMHStakeholderCouncilforassistance indefiningandrefiningMedicaid’sPCMHinitiativeandadoptingqualitymeasures forevaluation. TheMTMPCMHwasdevelopedusingthestructureofMedicaid’sPCCMprogram, PassporttoHealth. MedicaidmembersenrolledwithaPassporttoHealthprovider selectedtobeaMTMPCMHproviderwillautomaticallybepartofthatprovider’s PCMHcaseload. AnyMedicaidmembermaychangetoanotherPassportprovider orMTMPCMHprovider (accordingtoproceduresestablishedunderthe1915 (b) waiverPassporttoHealthorTeamCareprograms). MedicaidconductedtribalconsultationonDecember30, 2015, andpublicnoticeon December31, 2015, inaccordancewithCMSrequirements. D. StateAssurancesandCompliancewiththeStatuteandRegulations. Ifapplicabletothestateplan, placeacheckmarktoaffirmthatcompliancewiththe followingstatutesandregulationswillbemet. 1932(a)(1)(A)(i)(I) 1. Thestateassuresthatalloftheapplicablerequirementsof 1903(m) section1903(m) oftheAct, forMCOsandMCOcontractswillbemet. 42CFR438.50(c)(1) TN: 16-0003 ApprovalDate: 5/24/16 EffectiveDate: 1/1/2016 SupersedesTN: 14-0041

CMS-PM-10120 ATTACHMENT3.1-F Page4 OMBNo.:0938-0933 State: MONTANA Citation ConditionorRequirement 1932(a)(1)(A)(i)(I) 2. Thestateassuresthatalltheapplicablerequirementsofsection1905(t) 1905(t) oftheActforPCCMsandPCCMcontractswillbemet. 42CFR438.50(c)(2) 1902(a)(23)(A) 1932(a)(1)(A) 3. Thestateassuresthatalltheapplicablerequirementsofsection1932 42CFR438.50(c)(3) ( includingsubpart (a)(1)(A)) oftheAct, forthestate'soptiontolimitfreedom ofchoicebyrequiringBeneficiariestoreceivetheirbenefitsthroughmanaged careentitieswillbemet. 1932(a)(1)(A) 4. Thestateassuresthatalltheapplicablerequirementsof42CFR431.51 42CFR431.51 regardingfreedomofchoiceforfamilyplanningservicesandsuppliesas 1905(a)(4)(C) definedinsection1905(a)(4)(C) willbemet. 1932(a)(1)(A) 5. Thestateassuresthatitappropriatelyidentifiesindividualsinthe mandatoryexemptgroupsidentifiedin1932(a)(1)(A)(i). 1932(a)(1)(A) 6. Thestateassuresthatallapplicablemanagedcarerequirementsof 42CFR438 42CFRPart438forMCOsandPCCMswillbemet. 1903(m) 1932(a)(1)(A) 7. Thestateassuresthatallapplicablerequirementsof42CFR438.6(c) 42CFR438.6(c) forpaymentsunderanyriskcontractswillbemet. 42CFR438.50(c)(6) 42CFR438.50(c)(6) 8. Thestateassuresthatallapplicablerequirementsof42CFR447.362for42 CFR447.362 paymentsunderanynon-riskcontractswillbemet. 45CFR92.36 9. Thestateassuresthatallapplicablerequirementsof45CFR92.36for procurementofcontractswillbemet. 1932(a)(1)(A) E. PopulationsandGeographicArea 1932(a)(2) IncludedPopulations. 1. Pleasecheckwhicheligibilitypopulationsareincluded, iftheyareenrolledonamandatory (M) orvoluntary (V) basis, andthe geographicscopeofenrollment. Underthegeographycolumn, pleaseindicate whetherthenatureofthepopulation’senrollmentisonastatewidebasis, orif onlessthanastatewidebasis, pleaselisttheapplicablecounties/regions. TN: 16-0003 ApprovalDate: 5/24/16 EffectiveDate: 1/1/2016 SupersedesTN: 14-0041

CMS-PM-10120 ATTACHMENT3.1-F Page5 OMBNo.:0938-0933 State: MONTANA Citation ConditionorRequirement Population M GeographicArea V GeographicArea Excluded Section1931Children & RelatedPopulations – Tobedetermined 1905(a)(i) Section1931Adults & Tobedetermined Related Populations1905(a)(ii) Low-IncomeAdultGroup NA FormerFosterCareChildren underage21 FormerFosterCareChildren age21-25 Section1925Transitional Medicaidage21andolder Tobedetermined SSIandSSIrelatedBlind Adults, age18orolder* - Tobedetermined 1905(a)(iv) PovertyLevelPregnant Tobedetermined Women – 1905(a)(viii) SSIandSSIrelatedBlind Children, generallyunderage Tobedetermined 18 – 1905(a)(iv) SSIandSSIrelatedDisabled Tobedetermined childrenunderage18 SSIandSSIrelatedDisabled adultsage18andolder – Tobedetermined 1905(a)(v) AllMontanaMedicaidmembersenrolledinPassporttoHealthandTeamCareareeligibletovoluntarilyparticipate intheMTMPCMH. GeographicareasfortheMedicaidPCMHinitiativewillonlybelimitedbythenumberand locationofMTMPCMHproviderswillingtoenroll. TN: 16-0003 ApprovalDate: 5/24/16 EffectiveDate: 1/1/2016 SupersedesTN: 14-0041

CMS-PM-10120 ATTACHMENT3.1-F Page6 OMBNo.:0938-0933 State: MONTANA Citation ConditionorRequirement SSIandSSIRelatedAged Populationsage65orolder- Tobedetermined 1905(a)(iii) SSIRelatedGroupsExempt fromMandatoryManaged NA Careunder1932(a)(2)(B) RecipientsEligiblefor Medicare AmericanIndian/Alaskan Tobedetermined Natives Childrenunder19whoare Tobedetermined eligibleforSSI Childrenunder19whoare eligibleunderSection NA 1902(e)(3) Childrenunder19infoster careorotherin-home placement Childrenunder19receiving servicesfundedundersection 501(a)(1)(D) oftitleVandin accordancewith42CFR 438.50(d)(v) Other- Individualsatorbelow133% Tobedetermined FPLAge19through64 – 1902 (a)(10)(A)(i)( VIII) ExcludedGroups. 2. Withinthepopulationsidentifiedabove asMandatoryor Voluntary, theremaybecertaingroupsofindividualswhoareexcludedfromthe managedcareprogram. Pleaseindicateifanyofthefollowinggroupsareexcludedfrom participatingintheprogram: OtherInsurance--Medicaidbeneficiarieswhohaveotherhealthinsurance. Excludedifotherinsuranceoffersacasemanagementprogram. ResideinNursingFacilityorICF/MR--MedicaidbeneficiarieswhoresideinNursing Facilities (NF) orIntermediateCareFacilitiesfortheMentallyRetarded (ICF/MR). EnrolledinAnotherManagedCareProgram--Medicaidbeneficiarieswhoareenrolled inanotherMedicaidmanagedcareprogram. TN: 16-0003 ApprovalDate: 5/24/16 EffectiveDate: 1/1/2016 SupersedesTN: 14-0041

CMS-PM-10120 ATTACHMENT3.1-F Page7 OMBNo.:0938-0933 State: MONTANA Citation ConditionorRequirement EligibilityLessThan3Months--Medicaidbeneficiarieswhowouldhavelessthan threemonthsofMedicaideligibilityremaininguponenrollmentintotheprogram. ParticipateinHCBSWaiver--MedicaidbeneficiarieswhoparticipateinaHomeand CommunityBasedWaiver (HCBS, alsoreferredtoasa1915(c) waiver). RetroactiveEligibility–Medicaidbeneficiariesfortheperiodofretroactiveeligibility. Other (Pleasedefine): Excluded: Medicaredualeligible, membersresidinginanursingfacilityor ICF/IID, memberseligiblelessthan3months, membersenrolledinanHCBSwaiver oraHCBSstateplan, memberswithretroactiveeligibility, medicallyneedy memberswithaspenddown, subsidizedadoptionmembers, memberswhoare unabletofindaPCPwhoiswillingtoprovidecasemanagement, eligibleforPlan First, eligibleforFosterCare, receivingMedicaidunderPresumptiveEligibility, membersenrolledinMedicaidfundedthirdpartyadministrator (TPA) services, and membersresidinginaPsychiatricResidentialTreatmentFacility. Exempt: MemberswithTPLthatoffersacasemanagementprogram, outofstate fostercare, membersresidinginanoutofstatetreatmentcenter, memberswhodo nothave30days’ noticeoftheirproviderleaving, membersPCPrefusestosee themorprovidereferrals, membersintheNICU, memberrequestsamedical hardship, membersadmittedtoatreatmentcenter, correctingerrorsofmembers enrollment. 1932(a)(4) F. EnrollmentProcess. 1. Definitions. a. AutoAssignment- assignmentofabeneficiarytoahealthplanwhenthe beneficiaryhasnothadanopportunitytoselecttheirhealthplan. b. DefaultAssignment- assignmentofabeneficiarytoahealthplanwhenthe beneficiaryhashadanopportunitytoselecttheirhealthplan. TN: 16-0003 ApprovalDate: 5/24/16 EffectiveDate: 1/1/2016 SupersedesTN: 14-0041

CMSPM-10120 ATTACHMENT3.1F Page8 OMBNo.:0938-0933 State: MONTANA Citation ConditionorRequirement 2. Pleasedescribehowthestateeffectuatestheenrollmentprocess. Selectan enrollmentmethodologyfromthefollowingoptionsanddescribetheelementslisted beneathit: a. Theapplicantispermittedtoselectahealthplanatthetimeofapplication. i. Howthestatefulfillsitsobligationstoprovideinformationasspecifiedin 42CFR438.10(e). ii. Whatactionthestatetakesiftheapplicantdoesnotindicateaplan selectionontheapplication. iii. Ifactionincludesmakingadefaultassignment, describethealgorithm usedandhowitmeetsalloftherequirementsof42CFR438.50(f). iv. Thestate'sprocessfornotifyingthebeneficiaryofthedefaultassignment. Example: stategeneratedcorrespondence.) b. Thebeneficiaryhasanactivechoiceperiodfollowingtheeligibility determination. i. Howthebeneficiaryisnotifiedoftheirinitialchoiceperiod, includingits duration. TheMedicaidmemberisnotifiedoftheinitialchoiceperiod, includingits duration, byletterandbyatelephonecallfromMedicaid’sPassportto HealthEnrollmentBroker. ii. Howthestatefulfillsitsobligationstoprovideinformationasspecifiedin 42CFR438.10(e). TheStatefulfillsitsobligationstoprovideinformationforpotential enrolleesthroughPassporttoHealthEnrollmentBrokertelephonecalls, theWelcometoPassportmailing. TN: 16-0003 ApprovalDate: 5/24/16 EffectiveDate: 1/1/2016 SupersedesTN: 14-0041

CMS-PM-10120 ATTACHMENT3.1-F Page9 OMBNo.:0938-0933 State: MONTANA Citation ConditionorRequirement iii. Describethealgorithmusedfordefaultassignmentanddescribethe algorithmusedandhowitmeetsalloftherequirementsof42CFR 438.50(f). ThePCMHProgramwillusethePassporttoHealthalgorithm. Passport toHealthauto-assignsmemberstoaprovideriftheyhavenotchosenone, sixtydaysormoreafterthefirstoutreachattempt. Theautoassignment isintendedtochoosethebestsuitedPCPforamember. Thesystem assignsbythefollowingcriteria, inthisorder: 1. PreviousPassportenrollment, 2. Mostcurrentclaimshistory, 3. Case (family) Passportassignment(s), 4. NativeAmericanswillbeassignedtoIHSifoneiswithinfiftymiles oftheirhome, and 5. Geographicarea (withinafiftymileradius). iii. Thestate'sprocessfornotifyingthebeneficiaryofthedefaultassignment. TheMedicaidmemberisnotifiedoftheMTMPCMHdefaultassignment byletterfromtheMTMPCMH andconfirmationletterfromtheState’s EnrollmentBroker. c. Thebeneficiaryisauto-assignedtoahealthplanimmediatelyuponbeing determinedeligible. i. Howthestatefulfillsitsobligationstoprovideinformationasspecifiedin 42CFR438.10(e). ii. Thestate'sprocessfornotifyingthebeneficiaryoftheauto-assignment. Example: stategeneratedcorrespondence.) iii. Describethealgorithmusedforauto-assignmentanddescribethe algorithmusedandhowitmeetsalloftherequirementsof42CFR 438.50(f). 1932(a)(4) 3. Stateassurancesontheenrollmentprocess. 42CFR438.50 Placeacheckmarktoaffirmthestatehasmetalloftheapplicablerequirementsof choice, enrollment, andre-enrollment. a. ThestateassuresithasanenrollmentsystemthatallowsBeneficiarieswho arealreadyenrolledtobegivenprioritytocontinuethatenrollmentiftheMCO orPCCMdoesnothavecapacitytoacceptallwhoareseekingenrollmentunder theprogram. TN: 16-0003 ApprovalDate: 5/24/16 EffectiveDate: 1/1/2016 SupersedesTN: 14-0041

CMS-PM-10120 ATTACHMENT3.1-F Page10 OMBNo.:0938-0933 State: MONTANA Citation ConditionorRequirement b. Thestateassuresthat, perthechoicerequirementsin42CFR438.52, MedicaidBeneficiariesenrolledineitheranMCOorPCCMmodelwillhavea choiceofatleasttwoentitiesunlesstheareaisconsideredruralasdefinedin42 CFR438.52(b)(3). c. Thestateplanprogramappliestheruralexceptiontochoicerequirementsof 42CFR438.52(a) forMCOsandPCCMsinaccordancewith42CFR438.52(b). Pleaselisttheimpactedruralcounties: Thisprovisionisnotapplicabletothis1932StatePlanAmendment. d. Thestateappliestheautomaticreenrollmentprovisioninaccordance with42CFR438.56(g) iftherecipientisdisenrolledsolelybecauseheorshe losesMedicaideligibilityforaperiodof2monthsorless. Thisprovisionisnotapplicabletothis1932StatePlanAmendment. 1932(a)(4) G. Disenrollment. 42CFR438.56 1. Thestatewill/ willnot limitdisenrollmentformanagedcare. MontanaMedicaidwillnotpreventamemberfromdisenrollingfromaMTMPCMH providerandchoosingadifferentMTMPCMHorPassporttoHealthprovider. 2. ThedisenrollmentlimitationwillapplyforChooseanitem. months (upto12 months). NA 3. Thestateassuresthatbeneficiaryrequestsfordisenrollment (with andwithoutcause) willbepermittedinaccordancewith42CFR438.56(c). 4. Describethestate'sprocessfornotifyingtheMedicaidBeneficiariesoftheirrightto disenrollwithoutcauseduringthefirst90daysoftheirenrollment. (Examples: state generatedcorrespondence, HMOenrollmentpacketsetc.) MontanaMedicaidprovideseducationalmaterialstoeachmemberenrolledwitha PCMH. Thematerialsexplaintheprocessformemberstodisenrollfromaprovider. Membereducationisprovidedthroughseveralvenuesincludingletters, emails and/ortextsifapplicable, andtelephonecalls. Membereducationisalsoundertaken duringofficevisitstothepatient’smedicalhome. 5. Describeanyadditionalcircumstancesof “cause” fordisenrollment (ifany). Nospecific “cause” isneededonthepartofaMedicaidmembertodisenrollfroma MTMPCMHprovider. TN: 16-0003 ApprovalDate: 5/24/16 EffectiveDate: 1/1/2016 SupersedesTN: 14-0041

CMS-PM-10120 ATTACHMENT3.1-F Page11 OMBNo.:0938-0933 State: MONTANA Citation ConditionorRequirement H. Information RequirementsforBeneficiaries 1932(a)(5)(c) Thestateassuresthatitsstateplanprogramisincompliancewith42CFR 42CFR438.50 438.10(e) forinformationrequirementsspecifictoMCOsandPCCMprograms 42CFR438.10 operatedundersection1932(a)(1)(A)(i) stateplanamendments. 1932(a)(5)(D)(b) I. ListallbenefitsforwhichtheMCOisresponsible. 1903(m) N/A 1905(t)(3) 1932(a)(5)(D)(b)(4) J. Thestateassuresthateachmanagedcareorganizationhasestablishedan 42CFR438.228 internalgrievanceprocedureforenrollees. 1932(a)(5)(D)(b)(5) K. Describehowthestatehasassuredadequatecapacityandservices. 42CFR438.206 ForMontana’sPCMHinitiative, TheDepartmentwillbegintheprogramwitha limitednumberofPCMHproviders. MedicaidmemberswhosePassportprovideris notaMTMPCMHhaveaccesstotheirPassportproviderandtheabilitytochange toanotherPassportprovideronceamonthasdesired. 42CFR438.207 1932(a)(5)(D)(c)(1)(A) L. Thestateassuresthataqualityassessmentandimprovementstrategyhas 42CFR438.240 beendevelopedandimplemented. 1932(a)(5)(D)(c)(2)(A) M. Thestateassuresthatanexternalindependentreviewconductedbya 42CFR438.350 qualifiedindependententitywillbeperformedyearly. 1932 (a)(1)(A)(ii) N. SelectiveContractingUndera1932StatePlanOption Torespondtoitems #1and #2, placeacheckmark. Thethirditemrequiresabrief narrative. 1. Thestatewill/ willnot intentionallylimitthenumberofentitiesitcontracts undera1932stateplanoption. 2. Thestateassuresthatifitlimitsthenumberofcontractingentities, this limitationwillnotsubstantiallyimpairbeneficiaryaccesstoservices. TN: 16-0003 ApprovalDate: 5/24/16 EffectiveDate: 1/1/2016 SupersedesTN: 14-0041

CMS-PM-10120 ATTACHMENT3.1-F Page12 OMBNo.:0938-0933 State: MONTANA Citation ConditionorRequirement 3. Describethecriteriathestateusestolimitthenumberofentitiesitcontracts undera1932stateplanoption. (Example: alimitednumberofprovidersand/or enrollees.) MontanaMedicaidbeginstheMTMPCMHProgramwithalimitednumberof providers. TheStatewillrateproviderMTMPCMHapplicantsbasedonNCQA recognition, PassporttoHealthstatus, numbersandtypesofprovidersinthe PCMHpractice, PCMHmodel, andqualificationbyMontana’sCommissioner ofSecuritiesandInsurance (CSI). Oncethepilotcansendandreceivedata, qualified (NCQArecognizedandapprovedbyCSI) providerswillbeadded uponrequesttotheDepartment. 4. Theselectivecontractingprovisioninnotapplicabletothisstateplan. TN: 16-0003 ApprovalDate: 5/24/16 EffectiveDate: 1/1/2016 SupersedesTN: 14-0041

Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: MT- 16- 0007 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Approved SPA Pages TN: MT- 16- 0007 Approval Date: 02/ 06/ 2017 Effective Date 10/ 01/ 2016

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare & Medicaid Services 1961 Stout Street, Room 08- 148 cm s Denver, CO 80294 Region VIII February 6, 2017 Mary Dalton, Medicaid & CHIP Director Montana Department of Public Health & Human Services P. O. Box 4210 Helena, MT 59604 Re: SPA MT- 16- 0007 Dear Ms. Dalton: The Centers for Medicare & Medicaid Services ( CMS) has approved the Montana state plan amendment ( SPA) 16- 0007. This amendment permits Montana to provide continuous Medicaid eligibility for children under the age of 19 for a full year, regardless of whether the child continuously meets all eligibility requirements during the continuous eligibility period. The amendment is effective as of October 1, 2016. The CMS- 179 form and amended plan page are enclosed. Section 1902( e)( 12) of the Act requires that when a state elects the continuous eligibility option, it must extend continuous eligibility to all children categorically eligible under section 1902( a)( 10)( A) of the Act. While the state has adopted the policy to provide continuous eligibility for all children under age 19 enrolled in Medicaid, the Montana Department of Public Health & Human Services has indicated that it is possible that children whose Medicaid eligibility is based on their receipt of SSI will not be captured by the state' s current eligibility system as being continuously eligible if their SSI eligibility is terminated. Montana has informed CMS that it will complete the necessary system modifications to ensure that SSI-based children who lose SSI will be granted continuous eligibility. Montana has further indicated that it expects to complete this work by June 1, 2017. CMS requests that Montana provide monthly reports on its progress on the necessary eligibility systems upgrade by the 15th of each month to the CMS Regional Office, beginning March 2017.

If you have any questions regarding this SPA please contact Barbara Prehmus at ( 303) 844- 7472. Sincerely, Ric ard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations cc: Richard Opper, Department Director Duane Preshinger Jo Thompson Mary Eve Kulawik 2

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 16-0007 Montana FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT( MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 10/ 01/ 2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL( Check One): 0 NEW STATE PLAN Ej AMENDMENT TO BE CONSIDERED AS NEW PLAN Z AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2016 ( 3 mos): $ 0 section 1902( e)( 12) b. FFY 2017( 12 mos): $ 0 c. FFY 2018 ( 9 mos): $ 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable): Attachment 2. 2- A, Page 23c Attachment 2. 2- A, Page 23c 10. SUBJECT OF AMENDMENT: The purpose of this amendment is to provide all categorically needy children between the ages of 0- 19 with 12 months of continuous eligibility, regardless of changes in circumstances other than moving out of the State or attaining age 19. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OAS OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED Single Agency Director Review NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Montana Department of Public Health and Human Services Mary E. Dalton 13.' 1' YPED NAM1JMary E. Dalton Attn: Mary Eve Kulawik PO Box 4210 14. TITLE: State Medicaid Director Helena MT 59620 15. DATE SUBMITTED: FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: T 18. DATE APPROVED: June 21, 2016 February 6, 2017 PLAN APPROVED— ONE OFFICIAL: October 1 2016 21. TYPED NAME: Richard C. Allen ARA, DMCHO 23. REMARKS: FORM HCFA- 179 ( 07- 92)

Revision: CMS-PM- ATTACHMENT 2. 2- A Page 23c(i) OMB NO.: State: MONTANA Citation Groups Covered B. Optional Coverage Other Than the Medically Needy Continued) 1902( e)( 12) of the Act x 22a. Continuous Eligibility for Children. A child under age 19 ( not to exceed age 19) who has been determined eligible under §1902( a)( 10)( A) of the Act is deemed to be eligible for a total of 12 months ( not to exceed 12 months) regardless of changes in circumstances, other than moving out of the State or attainment of the maximum age stated above, until the earlier of: a. The end of a period( not to exceed 12 months) of continuous eligibility; or b. The time that the individual exceeds that age. TN No. 16-0007 Approval Date 2/ 6/ 17 Effective Date 10/ 01/ 16 Supersedes TN No. 10- 001

TableofContents State/TerritoryName: Montana StatePlanAmendment (SPA) #: MT-16-0020 Thisfilecontainsthefollowingdocumentsintheorderlisted: 1) ApprovalLetter 2) CMS179Form/SummaryForm (with179-likedata) 3) ApprovedSPAPages TN: ApprovalDate: EffectiveDate MT-16-002007/19/201606/01/2016

DEPARTMENTOFHEALTH & HUMANSERVICES CentersforMedicare & MedicaidServices 1961StoutStreet, Room08-148 Denver, CO 80294 RegionVIII July19, 2016 Ms. MaryE. Dalton StateMedicaidandCHIPDirector POBox4210 Helena, MT59601-4210 RE: SPA16-0020 DearMs. Dalton: WereviewedMontana'sproposedStatePlanAmendment (SPA) submittedundertransmittalnumber MT -16-0020. Thisamendmentimplementsfederalcost-sharingprovisionsforMontana’sMedicaid standardpopulationtoalignwiththeexpansionHELPpopulation. PleasebeinformedthatthisSPAwas approvedtodaywithaneffectivedateofJune1, 2016. WeareenclosingtheCMS179Formandthe approvedStatePlanpages. WenotethatintheSPAreviewprocess, webecameawareofotherissuesthatwewillbeaddressing separately. Welookforwardtoworkingwiththestatetoensureproperimplementationofall requirements. IfyouhaveanyquestionsregardingthisSPA, pleasecontactMaryMarchioniat (303) 844-7094. Sincerely, RichardC. Allen AssociateRegionalAdministrator DivisionofMedicaid & Children’sHealthOperations cc: RichardOpper, DepartmentDirector DuanePreshinger JoThompson MaryEveKulawik

Medicaid Premiums and Cost Sharing: Summary Page ( CMS 179) State/Territory name: Montana 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 16- 0020 Proposed Effective Date 06/01/ 2016 mm/ dd/ yyyy) Federal Statute/ Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First Year 1016 1 0. 00 Second YearPIT] 0. 00 Subject of Amendment Align Montana's Standard Medicaid Population with the expansion HELP Population. These changes address the following: a standard cost share amount for outpatient services, inpatient services and pharmacy services; and Medicaid cost sharing incurred will not exceed an aggregate limit of five percent of the family' s quarterly income. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Mary Eve Last Revision Date: Jun 22, 2016 Submit Date: Jun 22, 2016 Date Received: 22 June, 2016 Date Approved: 19 July, 2016 Signature of Approving Official:` ...';;;"' Printed Name and Title: Richard C. Allen, Associate Regional Administrator Division of Medicaid& Children' s Heatlh MT- 16-0020 Approval Date: 7/ 19/ 2016 Effective Date: 6/ 1/ 2016

MedicaidPremiumsandCostSharing OMBControlNumber: 09381148 StateName:Montana Expirationdate: 10/31/2014 TransmittalNumber:MT-16-0020 CostSharingAmounts - CategoricallyNeedyIndividualsG2a 1916 1916A 42CFR447.52through54 Thestatechargescostsharingtoallcategoricallyneedy (MandatoryCoverageandOptionsforCoverage) individuals. Yes ServicesorItemswiththeSameCostSharingAmountforAllIncomes Dollarsor ServiceorItemAmountPercentageUnitExplanation x InpatientHospital75.00 EntireStay x AmbulatorySurgical 4.00 State:Montana Visit Center DateReceived:6-22-2016 x Denturists4.00 DateApproved:7-19-2016 Visit DateEffective:6-1-2016 x DurableMedical 4.00 Visit TransmittalNumber:16-0020 Equipment x FederallyQualified 4.00 Visit HealthCenter x DialysisClinics4.00 Visit x OutpatientHospital4.00 Visit x RuralHealthClinic4.00 Visit HomeInfusion 4.00 x Therapy (codes99602 Visit and99601areexempt) Independent4.00 x DiagnosticTesting Visit Facilities x Mid-Level4.00 Visit Practitioners x Physician4.00 Visit x Podiatry4.00 Visit x Psychiatrists4.00 Visit x Dental4.00 Visit x HomeHealth4.00 Visit x LicensedProfessional 4.00 Visit Counselors x PsychologicalServices4.00 Visit TN:MT16-0020ApprovalDate:7-19-2016EffectiveDate:6/1/2016 SupersedesTN:NewPage Page1of3

MedicaidPremiumsandCostSharing Dollarsor ServiceorItemAmountPercentageUnitExplanation x SocialWorker4.00 Visit x SpeechTherapy4.00 Visit State:Montana x Audiology4.00 Visit DateReceived:6-22-2016 x DateApproved:7-19-2016 HearingAids4.00 Visit DateEffective:6-1-2016 x OccupationalTherapy4.00 Visit TransmittalNumber:16-0020 x Opticians4.00 Visit x Optometric4.00 Visit x PhysicalTherapy4.00 Visit x PublicHealthClinics4.00 Visit x Pharmacy4.00Forpreferredbrands. Prescription x Pharmacy8.00Fornon-preferred. Prescription x IndependentLaband 4.00 Visit X-RayServices x MentalHealthClinics4.00 Visit x ChemicalDependency 4.00 Visit Services ServicesorItemswithCostSharingAmountsthatVarybyIncome RemoveService ServiceorItem: orItem Indicatetheincomerangesbywhichthecostsharingamountforthisserviceoritemvaries. IncomesIncomesLess Dollarsor GreaterthanthanorEqualtoAmountPercentageUnitExplanation x Visit AddServiceorItem CostSharingforNon-preferredDrugsChargedtoOtherwiseExemptIndividuals Ifthestatechargescostsharingfornon-preferreddrugs (enteredabove), answerthefollowingquestion: Thestatechargescostsharingfornon-preferreddrugstootherwiseexemptindividuals. No TN:MT16-0020ApprovalDate:7-19-2016EffectiveDate:6-1-2016 SupersedesTN:NewPage Page2of3

MedicaidPremiumsandCostSharing CostSharingforNon-emergencyServicesProvidedintheHospitalEmergencyDepartmentChargedtoOtherwise ExemptIndividuals Ifthestatechargescostsharingfornon-emergencyservicesprovidedinthehospitalemergencydepartment (enteredabove), answer thefollowingquestion: Thestatechargescostsharingfornon-emergencyservicesprovidedinthehospitalemergencydepartmenttootherwise No exemptindividuals. PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis09381148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage40hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC42605, Baltimore, Maryland212441850. V.20140415 State:Montana DateReceived:6-22-2016 DateApproved:7-19-2016 DateEffective:6-1-2016 TransmittalNumber:16-0020 TN:MT16-0020ApprovalDate:7-19-2016EffectiveDate:6-1-2016 SupersedesTN:NewPage Page3of3

MedicaidPremiumsandCostSharing OMBControlNumber: 09381148 StateName:Montana Expirationdate: 10/31/2014 TransmittalNumber:MT-16-0020 State:Montana DateReceived:6-22-2016 CostSharingLimitationsG3 DateApproved:7-19-2016 DateEffective:6-1-2016 42CFR447.56 TransmittalNumber:16-0020 1916 1916A Thestateadministerscostsharinginaccordancewiththelimitationsdescribedat42CFR447.56, and1916(a)(2) and (j) and 1916A(b) oftheSocialSecurityAct, asfollows: Exemptions GroupsofIndividuals - MandatoryExemptions Thestatemaynotimposecostsharinguponthefollowinggroupsofindividuals: Individualsages1andolder, andunderage18eligibleundertheInfantsandChildrenunderAge18eligibilitygroup (42 CFR435.118). Infantsunderage1eligibleundertheInfantsandChildrenunderAge18eligibilitygroup (42CFR435.118), whoseincome doesnotexceedthehigherof: 133% FPL; and Ifapplicable, thepercentFPLdescribedinsection1902(l)( 2)(A)(iv) oftheAct, upto185percent. Disabledorblindindividualsunderage18eligibleforthefollowingeligibilitygroups: SSIBeneficiaries (42CFR435.120). BlindandDisabledIndividualsin209(b) States (42CFR435.121). IndividualsReceivingMandatoryStateSupplements (42CFR435.130). ChildrenforwhomchildwelfareservicesaremadeavailableunderPartBoftitleIVoftheActonthebasisofbeingachild infostercareandindividualsreceivingbenefitsunderPartEofthattitle, withoutregardtoage. DisabledchildreneligibleforMedicaidundertheFamilyOpportunityAct (1902(a)(10)(A)(ii)(XIX) and1902(cc) ofthe Act). Pregnantwomen, duringpregnancyandthroughthepostpartumperiodwhichbeginsonthelastdayofpregnancyand extendsthroughtheendofthemonthinwhichthe60-dayperiodfollowingterminationofpregnancyends, exceptforcost sharingforservicesspecifiedinthestateplanasnotpregnancy-related. Anyindividualwhosemedicalassistanceforservicesfurnishedinaninstitutionisreducedbyamountsreflectingavailable incomeotherthanrequiredforpersonalneeds. Anindividualreceivinghospicecare, asdefinedinsection1905(o) oftheAct. IndianswhoarecurrentlyreceivingorhaveeverreceivedanitemorservicefurnishedbyanIndianhealthcareprovideror throughreferralundercontracthealthservices. IndividualswhoarereceivingMedicaidbecauseofthestate'selectiontoextendcoveragetotheCertainIndividualsNeeding TreatmentforBreastorCervicalCancereligibilitygroup (42CFR435.213). TN:MT16-0020ApprovalDate:7-19-2016DateEffective:6-1-2016 SupersedesTN:NoneNewPage Page1of5

MedicaidPremiumsandCostSharing GroupsofIndividuals - OptionalExemptions Thestatemayelecttoexemptthefollowinggroupsofindividualsfromcostsharing: Thestateelectstoexemptindividualsunderage19, 20or21, oranyreasonablecategoryofindividuals18yearsofage Yes orover. Indicatebelowtheageoftheexemption: State:Montana Underage19 DateReceived:6-22-2016 DateApproved:7-19-2016 Underage20 DateEffective:6-1-2016 Underage21 TransmittalNumber:16-0020 Otherreasonablecategory Thestateelectstoexemptindividualswhosemedicalassistanceforservicesfurnishedinahomeandcommunity-based Yes settingisreducedbyamountsreflectingavailableincomeotherthanrequiredforpersonalneeds. Services - MandatoryExemptions Thestatemaynotimposecostsharingforthefollowingservices: Emergencyservicesasdefinedatsection1932(b)(2) oftheActand42CFR438.114(a). Familyplanningservicesandsuppliesdescribedinsection1905(a)(4)(C) oftheAct, includingcontraceptivesand pharmaceuticalsforwhichthestateclaimsorcouldclaimfederalmatchattheenhancedrateundersection1903(a)(5) ofthe Actforfamilyplanningservicesandsupplies. Preventiveservices, ataminimumtheservicesspecifiedat42CFR457.520, providedtochildrenunder18yearsofage regardlessoffamilyincome, whichreflectthewell-babyandwellchildcareandimmunizationsintheBrightFutures guidelinesissuedbytheAmericanAcademyofPediatrics. Pregnancy-relatedservices, includingthosedefinedat42CFR440.210(a)(2) and440.250(p), andcounselinganddrugsfor cessationoftobaccouse. Allservicesprovidedtopregnantwomenwillbeconsideredpregnancy-related, exceptthose servicesspecificiallyidentifiedinthestateplanasnotbeingrelatedtopregnancy. Provider-preventableservicesasdefinedin42CFR447.26(b). EnforceabilityofExemptions Theproceduresforimplementingandenforcingtheexemptionsfromcostsharingcontainedin42CFR447.56are (checkallthat apply): ToidentifythatAmericanIndians/AlaskanNatives (AI/AN) arecurrentlyreceivingorhaveeverreceivedanitemorservice furnishedbyanIndianhealthcareproviderorthroughreferralundercontracthealthservicesinaccordancewith42CFR 447.56(a)(1)(x), thestateusesthefollowingprocedures: Thestateacceptsself-attestation Thestaterunsperiodicclaimsreviews ThestateobtainsanActiveorPreviousUserLetterorotherIndianHealthServices (IHS) document TheEligibilityandEnrollmentandMMISsystemsflagexemptrecipients TN:MT16-0020ApprovalDate:7-19-2016DateEffective:6-1-2016 SupersedesTN:NoneNewPage Page2of5

MedicaidPremiumsandCostSharing Otherprocedure Additionaldescriptionofproceduresusedisprovidedbelow (optional): TheStateacceptsself-attestationinresponsetothequestiononthesinglestreamlinedapplicationinquiringwhetherthe applicanthaseverreceivedanitemoraservicefromanI/T/U. Toidentifyallotherindividualsexemptfromcostsharing, thestateusesthefollowingprocedures (checkallthatapply): TheMMISsystemflagsrecipientswhoareexempt TheEligibilityandEnrollmentSystemflagsrecipientswhoareexempt TheMedicaidcardindicatesifbeneficiaryisexempt TheEligibilityVerificationSystemnotifiesproviderswhenabeneficiaryisexempt Otherprocedure Additionaldescriptionofproceduresusedisprovidedbelow (optional): Costsharetrackingagainstthe5% householdcapwillapplytobothpremiumsandco-payments. Whentheparticipant paystheirpremium, thepaymentisappliedtotheaggregatehouseholdcapduringthequarterforwhichthepremiumis due. ThepreventiveservicesprotocolapprovedintheHealthandEconomicLivelihoodPlan (HELP) Medicaid1115waiver appliestoallcostsharing. PaymentstoProviders Thestatereducesthepaymentitmakestoaproviderbytheamountofabeneficiary'scostsharingobligation, regardlessof whethertheproviderhascollectedthepaymentorwaivedthecostsharing, exceptasprovidedunder42CFR447.56(c). PaymentstoManagedCareOrganizations ThestatecontractswithoneormoremanagedcareorganizationstodeliverservicesunderMedicaid.No AggregateLimits MedicaidpremiumsandcostsharingincurredbyallindividualsintheMedicaidhouseholddonotexceedanaggregatelimitof5 percentofthefamily'sincomeappliedonaquarterlyormonthlybasis. Thepercentageoffamilyincomeusedfortheaggregatelimitis: 5% 4% State:Montana 3% DateReceived:6-22-2016 DateApproved:7-19-2016 2% DateEffective:6-1-2016 1% TransmittalNumber:16-0020 Other: TN:MT16-0020DateApproved:7-19-2016DateEffective:6-1-2016 SupersededTNNewPage Page3of5

MedicaidPremiumsandCostSharing State:Montana DateReceived:6-22-2016 DateApproved:7-19-2016 Thestatecalculatesfamilyincomeforthepurposeoftheaggregatelimitonthefollowingbasis: DateEffective:6-1-2016 Quarterly TransmittalNumber:16-0020 Monthly Thestatehasaprocesstotrackeachfamily'sincurredpremiumsandcostsharingthroughamechanismthatdoesnot Yes relyonbeneficiarydocumentation. Describethemechanismbywhichthestatetrackseachfamily'sincurredpremiumsandcostsharing (checkallthat apply): Asclaimsaresubmittedfordatesofserviceswithinthefamily'scurrentmonthlyorquarterlycapperiod, thestate appliestheincurredcostsharingforthatservicetothefamily'saggregatelimit. Oncethefamilyreachesthe aggregatelimit, basedonincurredcostsharingandanyapplicablepremiums, thestatenotifiesthefamilyand providersthatthefamilyhasreachedtheiraggregatelimitforthecurrentmonthlyorquarterlycapperiod, andare nolongersubjecttopremiumsorcostsharing. Managedcareorganization(s) trackeachfamily'sincurredcostsharing, asfollows: Otherprocess: TheStateutilizesanelectronicdatasharingprogramthatevaluateswhethertheindividualissubjecttopremiums andco-paymentsorexempt, whethertheserviceisexemptfromaco-payment, andwhethertheindividualhashit the5% aggregatehouseholdcostsharingcap. Onadailybasis, payersystems— MMIS, TPAandPharmacyBenefitManager (PBM)—sendtheelectronicdatasharingprogramprocessedclaims. Onadailybasis, theelectronicdatasharingprogramwillsendupdatedcostsharingbalancestotheMMIS, TPA andPBM. Theproviderisnotifiedthrougharemittanceadviceoftheapplicableco-paymentandtheprovider willbillthebeneficiary. Describehowthestateinformsbeneficiariesandprovidersofthebeneficiaries' aggregatefamilylimitandnotifies beneficiariesandproviderswhenabeneficiaryhasincurredpremiumsandcostsharinguptotheaggregatefamilylimit andindividualfamilymembersarenolongersubjecttopremiumsorcostsharingfortheremainderofthefamily's currentmonthlyorquarterlycapperiod: TheStatewillissueawrittennoticetoabeneficiarywhenthebeneficiaryreachestheiraggregatehouseholdcap. Once themaximumaggregatelimitisreachedtheElectronicDataExchange (EDX) systemwillnotifytheStateandaletter willbeissuedthatnofurtherco-paywillbetakeninthatquarter. ThisfunctionalitywillbeinplaceJuly1st, 2016. Consumersmayaccessinformationregardingtheaggregatehouseholdlimitthroughthefollowingavenues: (1) aTPA hotlineforTPAenrollees; or (2) anMMIShotlineoronlineconsumerportalfornon-TPAenrollees. Thestatehasadocumentedappealsprocessforfamiliesthatbelievetheyhaveincurredpremiumsorcostsharingover Yes theaggregatelimitforthecurrentmonthlyorquarterlycapperiod. Describetheappealsprocessused: Thememberwillusethestandardfairhearingprocessiftheydisagreewithadecisionontheaggregatelimit. Torequesta fairhearingthemembermaycalltheOfficeofFairHearingsorsubmitaformwiththeircomplainttotheoffice. Thefair hearingprocessisdocumentedinARM37.5.307. Describetheprocessusedtoreimbursebeneficiariesand/orprovidersifthefamilyisidentifiedaspayingovertheaggregate limitforthemonth/quarter: Theclaimwillbereprocessedtoindicatenoco-pay. Theproviderisresponsibletoreimbursethememberforanyco-pay TN:MT16-0020DateApproved:7-19-2016DateEffective:6-1-2016 SupersedesTN:NoneNewPage Page4of5

MedicaidPremiumsandCostSharing thatwascollectedinerror. WhentheStatesendsanoticetothebeneficiarythattheyhitthe5% cap, thenoticewillalso includeinformationthattheymayhavebeenoverchargedbytheirproviderandtheyshouldreachouttotheproviderto seekreimbursement. Describetheprocessforbeneficiariestorequestareassessmentoftheirfamilyaggregatelimitiftheyhaveachangein circumstancesoriftheyarebeingterminatedforfailuretopayapremium: BeneficiarieswillcontacttheOfficeofPublicAssistance (OPA) andfollowtheprocessoutlinedbyOPA. Thestateimposesadditionalaggregatelimits, consistentwith42CFR447.56(f)( 5).No PRADisclosureStatement AccordingtothePaperworkReductionActof1995, nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysa validOMBcontrolnumber. ThevalidOMBcontrolnumberforthisinformationcollectionis09381148. Thetimerequiredtocomplete thisinformationcollectionisestimatedtoaverage40hoursperresponse, includingthetimetoreviewinstructions, searchexistingdata resources, gatherthedataneeded, andcompleteandreviewtheinformationcollection. Ifyouhavecommentsconcerningtheaccuracyof thetimeestimate(s) orsuggestionsforimprovingthisform, pleasewriteto: CMS, 7500SecurityBoulevard, Attn: PRAReportsClearance Officer, MailStopC42605, Baltimore, Maryland212441850. V.20140415 State:Montana DateReceived:6-22-2016 DateApproved:7-19-2016 DateEffective:6-1-2016 TransmittalNumber:16-0020 TN:MT16-0020DateApproved: 7-19-2016DateEffective: 6-1-2016 SupersedesTN:NoneNewPage Page5of5

Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: 18-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages TN: MT-18- 0007 Approval Date: 05/4/ 2018 Effective Date: 03/ 01/ 2018

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Denver Regional Office 1961 Stout Street, Room OS- 148 Denver, CO 80294 CMS CENTERS FOR MEDICARE& MEDICAID SERVICES REGION VIII- DENVER May 8, 2018 Marie Matthews, Medicaid & CHIP Director Montana Department of Public Health & Human Services P. O. Box 4210 Helena, MT 59604 Dear Ms. Matthews: We have reviewed the proposed State Plan Amendment( SPA) submitted under transmittal number MT- 18- 0007. This revised approval package is being issued as the original version, issued on May 4, 201S, had the wrong TN (MT-18- 0035). This amendment updates the eligibility requirements and removes the dietician from the required care team. Please be informed that this State Plan Amendment was approved May 4, 2018, with an effective date of March 1, 2018. We are enclosing the summary page and the amended plan page(s). In order to track expenditures associated with this amendment, Montana should follow the CMS - 64 reporting instructions outlined in Section 2500 of the State Medicaid Manual( SMM). For those individuals whose expenditures qualify for the newly eligible federal medical assistance percentage report on the Form CMS- 64.9 VIII Waiver, those not enrolled in the new adult group, claims should be reported on the Form CMS- 64.9 Base. For TCM Services for CYSHCN for beneficiaries under age 21, the expenditures should be reported on Line 24A — Targeted Case Management Services. If you have any questions regarding this SPA please contact Barbara Prehmus at( 303) 844- 7472. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations cc: Sheila Hogan, Department Director Duane Preshinger Jo Thompson Mary Eve Kulawik

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938- 0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 18- 0007 Montana FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: Title XIX of the Social Security Act( Medicaid) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 03/ 01/ 18 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT( Separate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Section 1915( g) a. FFY 2018:$ 0 b. FFY 2019:$ 0 c. FFY 2020:$ 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable): Supplements to Attachment 3. 1A and 3. 1B, Pages 1- 6 of 6, Supplements to Attachment 3. 1A and 3. 1B, Pages 1- 5 Service 19e for Targeted Case Management Services For Children and Service 19e for Targeted Case Management Services For Youth With Special Health Care Needs. Children and Youth With Special Health Care Needs 10. SUBJECT OF AMENDMENT: The TCM for Children and Youth with Special Health Care Needs will update the eligibility requirements and remove the dietician from the required care team. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED Single Agency Director Review. NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Montana Dept. of Public Health and Human Services Marie Matthews E State Medicaid Director Attn: Mary Eve Kulawik 13. TYPED NAME: Marie Matthews PO Box 4210 14. TITLE: State Medicaid Director Helena, MT 59604 15. DATE SUBMITTED: G+ FOR REGIb`NAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: March 7 2018 May 4 2018 PLAN APPROVED— ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: March 1 2018 21. TYPED NAME: 22. TITLE: Richard C. Allen ARA DMCHO 23. REMARKS: FORM HCFA- 179( 07- 92)

Supplement 1E to Attachment 3. 1A Service 19e Targeted Case Management ( TCM) Services for Children and Youth with Special Health Care Needs ( CYSHCN) Page 1 of 6 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/ Territory: Montana Target Group ( 42 Code of Federal Regulations 441. 18( 8) ( i) and 441. 18( 9) ) : Describe target group and any subgroups. If any of the following differs among the subgroups, submit a separate State plan amendment describing case management services furnished; qualifications of case management providers; or methodology under which case management providers will be paid.] A child who is receiving Medicaid or is presumptively eligible for Medicaid is eligible if they meet one of the requirements in ( a) or( b) and meets one of the requirements in ( c) : a) The child is under the age of one and meets one of the following: i)was born to a mother who abused drugs or alcohol during her pregnancy; ii)was born prior to 37 weeks gestation; iii)was born at a birth weight of less than 2500 grams; iv) the Department has care and placement authority, a voluntary services agreement or a voluntary placement agreement with the parents/ guardians; or b) The child is birth through 18 years of age and meets one of the following: i)is infected with the human immunodeficiency virus ( HIV) , as determined by a positive HIV antibody or antigen test, or who has a diagnosis of HIV disease or AIDS; ii)has been diagnosed with a congenital heart condition; iii)has been diagnosed with a neurological disorder or brain injury; iv)has been diagnosed with a condition that requires use of a ventilator; v) has been diagnosed with a condition that causes paraplegia or quadriplegia; vi) has been diagnosed with failure to thrive in the past year; or vii) has been diagnosed with another chronic physical health condition that is expected to last at least 12 months and causes difficulty performing activities of daily living; and c) The child is at high risk for medical compromise due to one of the following: i)failure to take advantage of necessary health care services; ii)noncompliance with their prescribed medication regime; or iii)an inability to coordinate multiple medical, social, and other services. X) Target group includes individuals transitioning to a community setting. Case- management services will be made available for up to 180 consecutive days of a covered stay in a medical institution. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions) . (State Medicaid Directors Letter (SMDL) , July 25, 2000) TN No 18- 0007 Approved 5/ 4/ 18 Effective 3/ 1/ 18 Supersedes 08- 021 Outline Version 9. 15. 2009

Supplement 1E to Attachment 3. 1A Service 19e Targeted Case Management ( TCM) Services for Children and Youth with Special Health Care Needs ( CYSHCN) Page 2 of 6 MONTANA Areas of State in which services will be provided (,A915( g) ( 1) of the Act: X) Entire State Only in the following geographic areas ( authority of section 1915( g) ( 1) of the Act is invoked to provide services less than Statewide) Comparability of Services (§ 1902 ( a) ( 10) ( B) and 1915( g) ( 1) : Services are provided in accordance with section 1902 ( a) ( 10) ( B) of the Act. X) Services are not comparable in amount, duration, and scope § 1915( g) ( 1) ) . Definition of Services ( 42 CFR 440. 169) : Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services. Targeted case management includes the following assistance: Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include taking client history; identifying the individual' s needs and completing related documentation; and gathering information from other sources such as family members, medical providers, social workers, and educators ( if necessary) , to form a complete assessment of the eligible individual; Specify and justify the frequency of assessments.] Assessments are conducted annually. Reassessments are conducted as needed on a case- by- case basis. Development ( and periodic revision) of a specific care plan that is based on the information collected through the assessment that specifies the goals and actions to address the medical, social, educational, and other services needed by the individual; includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual' s authorized health care decision maker) and others to develop those goals; and identifies a course of action to respond to the assessed needs of the eligible individual; Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and TN No 18- 0007 Approved 5/ 4/ 18 Effective 3/ 1/ 18 Supersedes 08- 021 Outline Version 9. 15. 2009

Supplement 1E to Attachment 3. 1A Service 19e Targeted Case Management ( TCM) Services for Children and Youth with Special Health Care Needs ( CYSHCN) Page 3 of 6 Montana Monitoring and follow- up activities: activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual' s needs, and which may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met: o services are being furnished in accordance with the individual' s care plan; o services in the care plan are adequate; and o changes in the needs or status of the individual are reflected in the care plan. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers. Specify the type of monitoring and justify the frequency of monitoring.] Types of monitoring may include face- to- face, by telephone, and via telehealth. Monitoring will occur as frequently as necessary, to include at least one annual monitoring, according to 42 CFR 440. 169( d) ( 4) . X) Case management includes contacts with non- eligible individuals that are directly related to identifying the eligible individual' s needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual' s needs. ( 42 CFR 440. 169( e) ) Qualifications of Providers ( 42 CFR 441. 18( a) ( 8) ( v) and 42 CFR 441. 18( b) ) : Specify provider qualifications that are reasonably related to the population being served and the case management services furnished.] Any provider who meets the TCM for CYSHCN provider qualifications may furnish TCM to the target group: 1. Experience in the delivery of home and community services to the target group; 2. Experience working with low- income families, especially children; 3. Demonstrated linkages and referral ability with essential social and health services agencies and individual practitioners in the area to be served; 4. Demonstrated knowledge of federal, state and local programs for children, such as: Title V programs, WIC, immunizations, perinatal health care, family planning, genetic services, hepatitis B screening, EPSDT, etc.; and nationally recognized perinatal and child health care standards; 5. Approval by the Montana Department of Public Health and Human Services ( DPHHS) ; TN No 18- 0007 Approved 5/ 4/ 18 Effective 3/ 1/ 18 Supersedes 08- 021 Outline Version 9. 15. 2009

Montana Supplement lE to Attachment 3. lA Service 19e Targeted Case Management ( TCM) Services for Children and Youth with Special Health Care Needs ( CYSHCN) Page 4 of 6 6. An interdisciplinary team that includes members from the professions of nursing and social work. With approval from Montana DPHHS, a qualified paraprofessional may also be part of the team. The requirements for the TCM team members are as follows: a. A nurse who is currently licensed in Montana as either: i. a registered nurse who also holds a current Montana license, which includes course work in public health; or ii. a certified nurse practitioner who also holds a current Montana license; b. A social worker with: i. a master' s degree in social work ( MSW) or counseling; orii. a bachelor' s degree in social work ( BSW) with two years' experience; and c. If the TCM team includes a paraprofessional, that individual must have an Associate Degree in Behavioral Sciences or related field and two years of closely related work experience, and complete a state-sponsored training for paraprofessional case managers. Qualifying experience may be substituted, year for year, for education. The paraprofessional must work under the direct supervision of a qualified professional team member, as defined in this subsection, who would conduct a preliminary member assessment and determine the suitability of using a paraprofessional as part of the targeted case management team. 7. To accommodate special agency and geographic needs and circumstances, exceptions to the staffing requirements may be allowed if approved by DPHHS. However, the TCM provider must directly employ at a minimum either a nurse or a social worker. The other discipline may be provided through subcontracts. If services are provided through a subcontractor, the subcontract must be submitted to DPHHS or its designee for review and approval. Freedom of Choice ( 42) CFR 441. lB(a) (1)): 1. The State assures that the provision of case management services will not restrict an individual' s free choice of providers in violation of section 1902( a) (23) of the Act. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan. 2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan. Freedom of Choice Exception (§ 1915( g) (1) and 42 CFR 441. lB(b)) _<-> Target group consists of eligible individuals with developmental disabilities or with chronic mental illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental illness receive needed services: [ Identify any limitations to be imposed on the providers and specify how these limitations enable providers to ensure that individuals within the target groups receive needed services.] TN No 18- 0007 Supersedes 08- 021 Approved 5/ 4/ 18 Outline Version 9. 15. 2009 Effective 3/ 1/ 08

Supplement 1E to Attachment 3. 1A Service 19e Targeted Case Management ( TCM) Services for Children and Youth with Special Health Care Needs ( CYSHCN) Page 5 of 6 Montana Access to Services ( 42 CFR 441. 18( a) ( 2) , 42 CFR 441. 18( a) ( 3) , 42 CFR 441. 18( a) ( 6) ) : The State assures the following: Case management ( including targeted case management) services will not be used to restrict an individual' s access to other services under the plan. Individuals will not be compelled to receive targeted case management services, condition receipt of case management ( or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management ( or targeted case management) services; and Providers of case management services do not exercise the agency' s authority to authorize or deny the provision of other services under the plan. Payment ( 42 CFR 441. 18( a) ( 4) ) : Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. Case Records ( 42 CFR 441. 18( a) ( 7) ) : Providers maintain case records that document for all individuals receiving targeted case management as follows: (i)The name of the individual; ( ii) The dates of the case management services; ( iii)The name of the provider agency ( if relevant) and the person providing the case management service; ( iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; ( v) Whether the individual has declined services in the care plan; ( vi) The need for, and occurrences of, coordination with other case managers; ( vii) A timeline for obtaining needed services; ( viii) A timeline for reevaluation of the plan. Limitations: Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440. 169 when the case management activities are an integral and inseparable component of another covered Medicaid service ( State Medicaid Manual ( SMM) 43O2. F) . Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440. 169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. ( 42 CFR 441. 18( c) ) TN No 18- 0007 Approved 5/ 4/ 18 Effective 3/ 1/ 18 Supersedes 08- 021 Outline Version 9. 15. 2009

Supplement 1E to Attachment 3. 1A Service 19e Targeted Case Management ( TCM) Services for Children and Youth with Special Health Care Needs ( CYSHCN) Page 6 of 6 Montana FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that is included in an individualized education program or individualized family service plan consistent with § 19O3( c) of the Act. 1902 ( a) ( 25) and 1905( c) ) Specify any additional limitations.] The following activities may not be billed as TCM and are not reimbursable as a unit of TCM: 1. Outreach, application, and referral activities; 2. Direct medical services, including counseling or the transportation or escort of members; 3. Duplicate payments that are made to public agencies or private entities under the State Plan and other program authorities; 4. Writing, recording, or entering case notes for the member' s files; 5. Coordination of the investigation of any suspected abuse, neglect, and/ or exploitation cases; 6. Travel to and from member activities; and 7. Any service less than 8 minutes duration if it is the only service provided that day. TN No 18- 0007 Approved 5/ 4/ 18 Effective 3/ 1/ 18 Supersedes 08- 021 Outline Version 9. 15. 2009

Supplement 1E to Attachment 3. 1B Service 19e Targeted Case Management ( TCM) Services for Children and Youth with Special Health Care Needs ( CYSHCN) Page 1 of 6 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/ Territory: Montana Target Group ( 42 Code of Federal Regulations 441. 18( 8) ( i) and 441. 18( 9) ) : Describe target group and any subgroups. If any of the following differs among the subgroups, submit a separate State plan amendment describing case management services furnished; qualifications of case management providers; or methodology under which case management providers will be paid.] A child who is receiving Medicaid or is presumptively eligible for Medicaid is eligible if they meet one of the requirements in ( a) or( b) and meets one of the requirements in ( c) : a) The child is under the age of one and meets one of the following: i)was born to a mother who abused drugs or alcohol during her pregnancy; ii)was born prior to 37 weeks gestation; iii)was born at a birth weight of less than 2500 grams; iv) the Department has care and placement authority, a voluntary services agreement or a voluntary placement agreement with the parents/ guardians; or b) The child is birth through 18 years of age and meets one of the following: i)is infected with the human immunodeficiency virus ( HIV) , as determined by a positive HIV antibody or antigen test, or who has a diagnosis of HIV disease or AIDS; ii)has been diagnosed with a congenital heart condition; iii)has been diagnosed with a neurological disorder or brain injury; iv)has been diagnosed with a condition that requires use of a ventilator; v) has been diagnosed with a condition that causes paraplegia or quadriplegia; vi) has been diagnosed with failure to thrive in the past year; or vii) has been diagnosed with another chronic physical health condition that is expected to last at least 12 months and causes difficulty performing activities of daily living; and c) The child is at high risk for medical compromise due to one of the following: i)failure to take advantage of necessary health care services; ii)noncompliance with their prescribed medication regime; or iii)an inability to coordinate multiple medical, social, and other services. X) Target group includes individuals transitioning to a community setting. Case- management services will be made available for up to 180 consecutive days of a covered stay in a medical institution. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions) . (State Medicaid Directors Letter (SMDL) , July 25, 2000) TN No 18- 0007 Approved 5/ 4/ 18 Effective 3/ 1/ 18 Supersedes 08- 021 Outline Version 9. 15. 2009

Supplement 1E to Attachment 3. 1B Service 19e Targeted Case Management ( TCM) Services for Children and Youth with Special Health Care Needs ( CYSHCN) Page 2 of 6 MONTANA Areas of State in which services will be provided (,A915( g) ( 1) of the Act: X) Entire State Only in the following geographic areas ( authority of section 1915( g) ( 1) of the Act is invoked to provide services less than Statewide) Comparability of Services (§ 1902 ( a) ( 10) ( B) and 1915( g) ( 1) : Services are provided in accordance with section 1902 ( a) ( 10) ( B) of the Act. X) Services are not comparable in amount, duration, and scope § 1915( g) ( 1) ) . Definition of Services ( 42 CFR 440. 169) : Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services. Targeted case management includes the following assistance: Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include taking client history; identifying the individual' s needs and completing related documentation; and gathering information from other sources such as family members, medical providers, social workers, and educators ( if necessary) , to form a complete assessment of the eligible individual; Specify and justify the frequency of assessments.] Assessments are conducted annually. Reassessments are conducted as needed on a case- by- case basis. Development ( and periodic revision) of a specific care plan that is based on the information collected through the assessment that specifies the goals and actions to address the medical, social, educational, and other services needed by the individual; includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual' s authorized health care decision maker) and others to develop those goals; and identifies a course of action to respond to the assessed needs of the eligible individual; Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and TN No 18- 0007 Approved 5/ 4/ 18 Effective 3/ 1/ 18 Supersedes 08- 021 Outline Version 9. 15. 2009

Supplement 1E to Attachment 3. 1B Service 19e Targeted Case Management ( TCM) Services for Children and Youth with Special Health Care Needs ( CYSHCN) Page 3 of 6 Montana Monitoring and follow- up activities: activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual' s needs, and which may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met: o services are being furnished in accordance with the individual' s care plan; o services in the care plan are adequate; and o changes in the needs or status of the individual are reflected in the care plan. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers. Specify the type of monitoring and justify the frequency of monitoring.] Types of monitoring may include face- to- face, by telephone, and via telehealth. Monitoring will occur as frequently as necessary, to include at least one annual monitoring, according to 42 CFR 440. 169( d) ( 4) . X) Case management includes contacts with non- eligible individuals that are directly related to identifying the eligible individual' s needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual' s needs. ( 42 CFR 440. 169( e) ) Qualifications of Providers ( 42 CFR 441. 18( a) ( 8) ( v) and 42 CFR 441. 18( b) ) : Specify provider qualifications that are reasonably related to the population being served and the case management services furnished.] Any provider who meets the TCM for CYSHCN provider qualifications may furnish TCM to the target group: 1. Experience in the delivery of home and community services to the target group; 2. Experience working with low- income families, especially children; 3. Demonstrated linkages and referral ability with essential social and health services agencies and individual practitioners in the area to be served; 4. Demonstrated knowledge of federal, state and local programs for children, such as: Title V programs, WIC, immunizations, perinatal health care, family planning, genetic services, hepatitis B screening, EPSDT, etc.; and nationally recognized perinatal and child health care standards; 5. Approval by the Montana Department of Public Health and Human Services ( DPHHS) ; TN No 18- 0007 Approved 5/ 4/ 18 Effective 3/ 1/ 18 Supersedes 08- 021 Outline Version 9. 15. 2009

Montana Supplement lE to Attachment 3. lB Service 19e Targeted Case Management ( TCM) Services for Children and Youth with Special Health Care Needs ( CYSHCN) Page 4 of 6 6. An interdisciplinary team that includes members from the professions of nursing and social work. With approval from Montana DPHHS, a qualified paraprofessional may also be part of the team. The requirements for the TCM team members are as follows: a. A nurse who is currently licensed in Montana as either: i. a registered nurse who also holds a current Montana license, which includes course work in public health; or ii. a certified nurse practitioner who also holds a current Montana license; b. A social worker with: i. a master' s degree in social work ( MSW) or counseling; orii. a bachelor' s degree in social work ( BSW) with two years' experience; and c. If the TCM team includes a paraprofessional, that individual must have an Associate Degree in Behavioral Sciences or related field and two years of closely related work experience, and complete a state-sponsored training for paraprofessional case managers. Qualifying experience may be substituted, year for year, for education. The paraprofessional must work under the direct supervision of a qualified professional team member, as defined in this subsection, who would conduct a preliminary member assessment and determine the suitability of using a paraprofessional as part of the targeted case management team. 7. To accommodate special agency and geographic needs and circumstances, exceptions to the staffing requirements may be allowed if approved by DPHHS. However, the TCM provider must directly employ at a minimum either a nurse or a social worker. The other discipline may be provided through subcontracts. If services are provided through a subcontractor, the subcontract must be submitted to DPHHS or its designee for review and approval. Freedom of Choice ( 42) CFR 441. lB(a) (1)): 1. The State assures that the provision of case management services will not restrict an individual' s free choice of providers in violation of section 1902( a) (23) of the Act. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan. 2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan. Freedom of Choice Exception (§ 1915( g) (1) and 42 CFR 441. lB(b)) _<-> Target group consists of eligible individuals with developmental disabilities or with chronic mental illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental illness receive needed services: [ Identify any limitations to be imposed on the providers and specify how these limitations enable providers to ensure that individuals within the target groups receive needed services.] TN No 18- 0007 Supersedes 08- 021 Approved 5/ 4/ 18 Outline Version 9. 15. 2009 Effective 3/ 1/ 08

Supplement 1E to Attachment 3. 1B Service 19e Targeted Case Management ( TCM) Services for Children and Youth with Special Health Care Needs ( CYSHCN) Page 5 of 6 Montana Access to Services ( 42 CFR 441. 18( a) ( 2) , 42 CFR 441. 18( a) ( 3) , 42 CFR 441. 18( a) ( 6) ) : The State assures the following: Case management ( including targeted case management) services will not be used to restrict an individual' s access to other services under the plan. Individuals will not be compelled to receive targeted case management services, condition receipt of case management ( or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management ( or targeted case management) services; and Providers of case management services do not exercise the agency' s authority to authorize or deny the provision of other services under the plan. Payment ( 42 CFR 441. 18( a) ( 4) ) : Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. Case Records ( 42 CFR 441. 18( a) ( 7) ) : Providers maintain case records that document for all individuals receiving targeted case management as follows: (i)The name of the individual; ( ii) The dates of the case management services; ( iii)The name of the provider agency ( if relevant) and the person providing the case management service; ( iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; ( v) Whether the individual has declined services in the care plan; ( vi) The need for, and occurrences of, coordination with other case managers; ( vii) A timeline for obtaining needed services; ( viii) A timeline for reevaluation of the plan. Limitations: Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440. 169 when the case management activities are an integral and inseparable component of another covered Medicaid service ( State Medicaid Manual ( SMM) 43O2. F) . Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §440. 169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. ( 42 CFR 441. 18( c) ) TN No 18- 0007 Approved 5/ 4/ 18 Effective 3/ 1/ 18 Supersedes 08- 021 Outline Version 9. 15. 2009

Supplement 1E to Attachment 3. 1B Service 19e Targeted Case Management ( TCM) Services for Children and Youth with Special Health Care Needs ( CYSHCN) Page 6 of 6 Montana FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that is included in an individualized education program or individualized family service plan consistent with § 19O3( c) of the Act. 1902 ( a) ( 25) and 1905( c) ) Specify any additional limitations.] The following activities may not be billed as TCM and are not reimbursable as a unit of TCM: 1. Outreach, application, and referral activities; 2. Direct medical services, including counseling or the transportation or escort of members; 3. Duplicate payments that are made to public agencies or private entities under the State Plan and other program authorities; 4. Writing, recording, or entering case notes for the member' s files; 5. Coordination of the investigation of any suspected abuse, neglect, and/ or exploitation cases; 6. Travel to and from member activities; and 7. Any service less than 8 minutes duration if it is the only service provided that day. TN No 18- 0007 Approved 5/ 4/ 18 Effective 3/ 1/ 18 Supersedes 08- 021 Outline Version 9. 15. 2009

TableofContents State/TerritoryName: Montana StatePlanAmendment (SPA) #: 19-0001 Thisfilecontainsthefollowingdocumentsintheorderlisted: 1) ApprovalLetter 2) 179 3) ApprovedSPAPages TN: MT-19-0001 ApprovalDate: 12/18/2019 EffectiveDate: 10/01/2019

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-14-26 Baltimore, Maryland 21244-1850 Center for Medicaid and CHIP Services Disabled and Elderly Health Programs Group December 18, 2019 Ms. Marie Matthews State Medicaid Director Montana Department of Public Health and Human Services P.O. Box 4210 Helena, MT 59620 Dear Ms. Matthews: The CMS Division of Pharmacy team has reviewed Montana’ s State Plan Amendment (SPA) 19- 0001 received in the Denver Regional Operations Group on September 30, 2019. This amendment proposes to allow the Division of Medicaid to comply with the Medicaid Drug Utilization Review (DUR) provisions included in Section 1004 of the Substance Use-Disorder Prevention that promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (P.L. 115-271). This amendment also proposes to allow the Division of Medicaid to comply with the requirements outlined in Montana House Bill 86 regarding a 7-day supply limit for opioid naïve members. Based on the information provided and consistent with the regulations at 42 CFR 430.20, we are pleased to inform you that SPA 19-0001 is approved with an effective date of October 1, 2019. A copy of the signed CMS-179 form, as well as the pages approved for incorporation into Montana’s state plan will be forwarded by the Denver Regional Operations Group. If you have any questions regarding this amendment, please contact Charlotte Amponsah at 410) 786-1092 or charlotte.amponsah@cms.hhs.gov. Sincerely, Cynthia R. Denemark, R.Ph. Deputy Director Division of Pharmacy cc: Richard C. Allen, Director, Denver Regional Operations Group Barbara Prehmus, Denver Regional Operations Group Mary Eve Kulawik, Analyst, Montana Medicaid Dani Feist, Pharmacy Program Officer, Montana Medicaid Dan Peterson, Bureau Chief, Montana Medicaid Shannon Sexauer, Pharmacist, Montana Medicaid Jennifer Rieden, Acting Division Administrator, Montana Medicaid

f) i)l'ARTM!, NT OP Ml'AL'J' ll "NI) HUMANSl'. R\ 11(:l::S Hl'! I.ITll ('/\Ill: HN! l.r.t:TNOI\ DMINlsTR,\l' ION ,. TRANSMffTAL ANDNOTJCE OFAPPROVAL 01' STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINIS1l' RATmN " f' O:" ReGJONALADMINISTRATOR " "-""-·----- HEALTl-1 CAREHNANCTNG ADMTNISTRATION DEPARTMENTOFBEALTHANDHUMANSERVICES 5 .. TYPEOFl'LANMATERIAL (Ch,n:J. Onll!): I.TR,t,, NSMITTALNUMBER: 19-0001 FUR.MAPPROVED OMS NO (» 3J--019J 12. STATEMontana 3.PROGRAMiDENTIFICATION: TITLEXIXOF THESOCIAL SECURITY ACT (MEDICAID)--------------·---- 4. PROPOSEDEFFBCTIVE DATE 10lOl12O1!J DNEW' STATE Pt.AN 0 AMEND1'!ENTT0 B: CCONS1DE: REDASNEWf>LAN [ 8l AMENDMENT COMPLETE BLOCKS 6THRLI 10 IFTHISISANAMENDMENT { Se»,11•,1f1tTninmirlal !01· 1uid1t11111t11dm110 6.FEDERAi., STATifTBIREGIJLATfONCITATION: 7.FEDERAL BUDGET IMPACT: Public Law 11 - 27l Section l004 a. FFY20: $0. 00Social Sec•rity AetSection 1902{a)(30)(A) 1:1. ffY 2 ! : SO. ODSocia! St1c11rityActS5ctiCIIJI905(a)(l2.) C, FFY:/. 2; S0.00 - S. l'AGENUMBfROF THEP,LA}i'SEC- IlONOR' 9, PAGENUMBEROf' TH£ SUPERSEDED PLAN SECTION ATTACHMENi'; OR AITACHMENT (lf,ipplicttblll!); Se<:tk>n4.26, DrugU!.ilb:.titior1Revte1.1• Prok' 11t!l, 74d, Pl! geIof! N/11., NewPaga) Suppl<lmenttoAJ:tachmcnl 3.1Aa:nd3.1B, Service 12a, PR:'! Cri:>ed SupplementtoAtnldm1ent 3. IA ad3. IB, Servk,a 12a, Pn:scribtd Dru&!J, l'a1 1-4l)f4 Drn11;5, P iill'.61- 4 of 4 10. SUBJECT OF AMENDMENT: neDl"llgUtilimtion Revew {DUR) Program isbeingaaieudecltoimpleme. nt theMedicaidDUltprovisio111includedi11Section100,. of\he Subsmnce Us,e-Di orcler Prevonti011rhat PromotesOr,ioidRecoveryi!ndTreatm, mt (SUPPORT) for P tienrsand Co111m1,niti<:5Act (P. L. IIS-271 )- A\: l,>I), t!lePrctrib Drogs pfl&ti! t,e, rtg mettdecll('> omplywi1htherequiremutsoutli1' 1£dinHomeBill (llll) 16re,gradi1:1ga 7- my supplyli i• foropioidn.arvemernbel'.I. lLGOYl: R.NOJi.' SJ; IJ;; Vl.6W ( Chr,-t0,'lt); 0GOVERNOR' SOFFICEREPORTED NOCOMMENT OTHER, ASSPECIFIED: 0COMMENTSOF GOVERNOR'SOPFICE F. NCL. OSED Sil' IJ!" AgencyDil"ectorReview 0NOREPLY RECEIVED WITHIN45DAYSOFSUBMlHAL 12. SIGNATURE Of' STATEAGENCY OFFICIAL: 16.RETURNTO; PO Box 4210; Helllla. Ml" 59ti2014, TITI.Ei; St:;iteM¢ 11i aidDir c(<ir 13.DATE SU. E!MlTI'ED: 9- 3. Q RiGIONAL01FlCE VS! ONLY ·-·-- 17.DATE RECEIVED: 11 !l. DATEAl'PitOVE.D: I•. EfPBCTIVEDATE OFAPPROVED MATERIAL: r2 A1,, umNATUREOFREGTONAL OFPIC!Al-: UM 21. TYPEDNAME: 22.11TLE; lJ. REMAR. KS: FOR.MHCFA-179 (07- 92) September 30, 2019 December 18, 2019 October 1, 2019 Trinia J. Hunt Acting Deputy Division Director, WROG

74d State/Territory: MONTANA Citation Section 4.26 Public Law 115-271 Section 1004 & 1902(a) (85) 1. Claims Review Limitations: The state shall perform the following reviews and actions for opioid claim limitations: A. Prospective Drug Utilization Review (ProdDUR) Point of Sale (POS) safety edit for opioid duplicate and early fill and exceeding state defined quantity and dosage limits for clinical appropriateness. A prior authorization shall be required for an override. B. ProDUR safety edit for exceeding state defined Morphine Milligram Equivalents (MME) limits (as recommended by clinical guidelines). A prior authorization shall be required for an override. C. Retrospective reviews on opioid prescriptions exceeding these above limitations on an ongoing basis. D. Retrospective Drug Utilization Review (RetroDUR) shall be performed to identify members receiving concurrent opioids and benzodiazepines and for those receiving concurrent opioids and antipsychotics on an ongoing basis. Education shall be provided to practitioners prescribing these medications. 2. Program to Monitor Antipsychotic Medications by Children: The state shall manage, monitor, and review antipsychotic medications for appropriateness for all children including foster children based on approved indications and clinical guidelines. 3. Fraud and Abuse Identification: The state DUR program has established a process that identifies potential fraud or abuse of controlled substances by enrolled individuals, health care providers and pharmacies TN No. 19-0001 Approval Date Effective Date 10/01/2019 Supersedes TN No. New Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment SUPPORT) for Patients and Communities Act Provisions

Page | of 4 Supplement to Attachment 3.14. Service |2a Prescribed Drugs MONTANA

Drugs covered by the Medicaid Program are subject to the following limitations:

1. Drugs must be prescribed by a physician or other licensed practitioner who is authorized by law to prescribe drugs and is recognized by the Medicaid program;

2.. Maintenance medications may be dispensed in quantities sufficient for a 90-day supply or 100 units, whichever is greater. Other medications may not be dispensed in quantities greater than a 34-day supply except where manufacturer packaging cannot be reduced to a smaller quantity, Opioid prescriptions dispensed to opioid naive members must not exceed a 7-day supply. The department posts. list of current drug classes which are considered maintenance medications on the department's web site at http://medicaidprovider.hhs.mt gov.

3... Drugs are not covered if they: a. Have been classified as “less than effective” by the Food and Drug Administration (FDA). (Drug, Efficacy Study Implementation (DESL) drugs); or b, Are produced by manufacturers who have not signed a rebate agreement with CMS.

4. Nursing facilities are responsible for providing over-the-counter laxatives, antacids, and aspirin to their residents as these items are included in the facility per diem rate determined by the Department.

5. Montana Medicaid will cover vaccines administered in an outpatient pharmacy setting.

6. The Department will reimburse for compounded nonrebatable Active Pharmaceutical Ingredient (API) bulk powders and excipients on the Department's maintained drug formulary.

7.. The Department will cover nonprescription folic acid, pyridoxine, and bronchosaline.

8... Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.

9. The Medicaid agency provides coverage for the following excluded or otherwise restricted drugs or classes of drugs, or their medical uses to all Medicaid recipients, including full benefit dual eligible beneficiaries under the Medicare Prescription Drug Benefit Part D.

© The following excluded drugs are covered:

M (a) agents when used for anorexia, weight loss, weight gain. Weight gain agents are covered when medically necessary, Agents when used for anorexia and weight loss continue as excluded drugs.

(b) agents when used to promote fertility

(c) agents when used for cosmetic purposes or hair growth

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(d) agents when used for the symptomatic relief cough and colds

(e) prescription vitamins and mineral products, except prenatal vitamins and fluoride

TN 19-0001 Approved Effective 10/01/2019 Supersedes [5-0023

Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: 20-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All MT - Submission Package - MT2020MS0001O - (MT-20-0005) - Eligibility CMS-10434 OMB 0938-1188 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid & CHIP Operations Group 601 East 12th Street, Suite 355 Kansas City, MO 64106-2898 Center for Medicaid & CHIP Services September 25, 2020 Marie Matthews Medicaid & CHIP Director Montana Department of Public Health & Human Services 111 North Sanders, Room 301 Helena, MT 59604 Re: Approval of State Plan Amendment MT-20-0005 Dear Marie Matthews: On June 30, 2020, the Centers for Medicare and Medicaid Services (CMS) received Montana State Plan Amendment (SPA) MT-20-0005 to apply a census income disregard for Medicaid eligibility groups subject to non-MAGI income methodology, and to migrate eligibility requirements already approved for those non-MAGI eligibility groups into the state plan. Additionally, this state plan amendment revises the MAGI methodology to account for reasonably predictable Ťuctuations in income. We approve Montana State Plan Amendment (SPA) MT-20-0005 on September 25, 2020 with an eſective date(s) of April 01, 2020. Name Date Created No items available If you have any questions regarding this amendment, please contact Barbara Prehmus at barbara.prehmus@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Program Operations Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions

Center for Medicaid & CHIP Services Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID N/A SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date N/A State Information State/Territory Name: Montana Medicaid Agency Name: Department of Public Health and Human Services Submission Component State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID N/A SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date N/A SPA ID and Eſective Date SPA ID MT-20-0005 Reviewable Unit Proposed Eſective Date Superseded SPA ID MAGI-Based Methodologies 4/1/2020 MT-13-0043 Non-MAGI Methodologies 4/1/2020 New Medically Needy Income Level 4/1/2020 MT-01-019 Handling of Excess Income (Spenddown) 4/1/2020 MT-92-02 and MT-93-23 Medically Needy Resource Level 4/1/2020 MT-97-004 Mandatory Eligibility Groups 4/1/2020 MT-19-0005 Qualiţed Medicare Beneţciaries 4/1/2020 MT-15-0016,06-005,01-001 Speciţed Low Income Medicare Beneţciaries 4/1/2020 MT-15-0016,06-005,01-001 Qualifying Individuals 4/1/2020 MT-15-0016,06-005,01-001 Optional Eligibility Groups 4/1/2020 MT-19-0005 Individuals Eligible for but Not Receiving Cash Assistance 4/1/2020 MT-15-0016,06-005,01-001 Individuals Eligible for Cash Except for Institutionalization 4/1/2020 MT-15-0016,06-005,01-001 Work Incentives 4/1/2020 MT15-0016, 06-005, 01-001 Medically Needy Pregnant Women 4/1/2020 MT-15-0016,06-005,01-001 Medically Needy Children under Age 18 4/1/2020 MT-15-0016,06-005,01-001 Medically Needy Reasonable Classiţcations of Individuals under Age 21 4/1/2020 MT-15-0016,06-005,01-001 Medically Needy Populations Based on Age, Blindness or Disability 4/1/2020 150016,09027,06005,01001 Page Number of the Superseded Plan Section or Attachment (If Applicable):

Supplements 8a (pages 2, 5), 8b (pages 1-4), and 8c (pages 1-2) to Attachment 2.6-A.

Addendum to Supplement 8a to Attachment 2.6-A (single page)

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID N/A SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives Proposal for Aged/Blind/Disabled Eligibility Categories Montana is proposing to continue excluding temporary census income from eligibility determinations for aged, blind or disabled members, through use of an income disregard under Section 1902(r)(2) of the Social Security Act.

Modiţed Adjusted Gross Income (MAGI) Eligibility Categories Montana is proposing to amend the MAGI-Based Methodologies state plan page to elect the reasonably predictable changes income methodology for Ťuctuating seasonal, temporary, self-employment and commission-based income. The methodology includes temporary census income, minimizing the impact on Medicaid eligibility of temporary census work for individuals whose eligibility uses MAGI-based methodologies.

New Applicants or Redetermination Montanans who apply for new Medicaid coverage (or an annual redetermination of coverage) will be permitted to annualize the temporary census income consistent with other types of seasonal employment. This means that if a Tribal Member or Urban American Indian applies, or is redetermined, for Medicaid when they are working as a census worker, the census income will be annualized over an entire year and only 1/12th of this temporary income will be considered in their eligibility determination. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2020 $0 Second 2021 $0 Federal Statute / Regulation Citation 1902(r)(2) 42 CFR 435.603 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID N/A SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date N/A Governor's OŰce Review No comment Comments received No response within 45 days Other

Medicaid State Plan Eligibility MAGI Based Methodologies MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-13-0043 System-Derived SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 The state will apply Modiţed Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603. A. Household Composition 1. 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. 2. In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: 3. In establishing household composition under the rules for non-ţlers set forth at 42 CFR 435.603(f)(3), the state elects the following age for children: a. The pregnant woman is counted just as herself. b. The pregnant woman is counted as herself, plus one. c. The pregnant woman is counted as herself, plus the number of children she is expected to deliver. a. Age 19 b. Age 19, or in the case of full-time students, age 21

MAGI Based Methodologies MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-13-0043 System-Derived SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Household Income Financial eligibility is determined consistent with the following provisions: 1. When determining eligibility for new applicants, ţnancial eligibility is based on current monthly income and family size. 2. When determining eligibility for current beneţciaries, ţnancial eligibility is based on: 3. In determining current monthly or projected annual household income, the state considers reasonably predictable changes in income: The methodology used by the state to account for and verify such change is: For eligibility determinations and renewals, the Agency will utilize a reasonable methodology for predictable increases and decreases in future income over a 12-month period. The methodology applies when the applicant/member has income deemed by the Agency as highly likely to Ťuctuate. This reasonable methodology will use the applicant/member’s self-attestation or documentation to prorate, or spread out, expected future changes over 12 months. The conversion will calculate an average monthly amount that will be added to the applicant/member’s current monthly non-Ťuctuating and income sources and will be used to determine eligibility for the applicant/member. For seasonal or otherwise regularly Ťuctuating income, the changes will be considered reasonably predictable if the applicant/member self-attests that for the upcoming year the annual amount of Ťuctuating income is approximately equal to the annual amount of that income for the current year. For income that has been veriţed as not recurring in the following year (such as temporary Census income or a one-time contract), the income will be expired from the budget after the period in which it was prorated and included. The following sources of income are recognized by the Agency as highly likely to Ťuctuate: 1. Self-employment 2. Seasonal/temporary earned income (includes temporary Census wages) 3. Commission based earned income The methodology used by the state to account for and verify such change is: For eligibility determinations and renewals, the Agency will utilize a reasonable methodology for predictable increases and decreases in future income over a 12-month period. The methodology applies when the applicant/member has income deemed by the Agency as highly likely to Ťuctuate. This reasonable methodology will use the applicant/member’s self-attestation or documentation to prorate, or spread out, expected future changes over 12 months. The conversion will calculate an average monthly amount that will be added to the applicant/member’s current monthly non-Ťuctuating and income sources and will be used to determine eligibility for the applicant/member. For seasonal or otherwise regularly Ťuctuating income, the changes will be considered reasonably predictable if the applicant/member self-attests that for the upcoming year the annual amount of Ťuctuating income is approximately equal to the annual amount of that income for the current year. For income that has been veriţed as not recurring in the following year (such as temporary Census income or a one-time contract), the income will be expired from the budget after the period in which it was prorated and included. The following sources of income are recognized by the Agency as highly likely to Ťuctuate: 1. Self-employment 2. Seasonal/temporary earned income (includes temporary Census wages) 3. Commission based earned income a. Current monthly household income and family size b. Projected annual household income and family size for the remaining months of the current calendar year. Yes No a. Include a prorated portion of a reasonably predictable increase in future income and/or family size. b. Account for a reasonably predictable decrease in future income and/or family size.

4. MAGI-based income is calculated using the ţnancial methodologies deţned in section 36B(d)(2)(B) of the Internal Revenue Code, except as described at 42 CFR 435.603(e), and without regard to whether an individual expects to ţle taxes. 5. Except as provided at 42 CFR 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. 6. In determining the eligibility of an individual using MAGI-based income, the state must subtract an amount equivalent to 5 percentage points of the federal poverty level for the applicable family size only to determine the eligibility of an individual for medical assistance under the eligibility group with the highest income standard using MAGI-based methodologies in the applicable Title of the Act, but not to determine eligibility for a particular eligibility group. 7. Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. The state uses a speciţc nominal amount and frequency. Explanation of the state's methodology for determining the nominal amount: Montana will exclude the irregular or infrequent cash support and will budget cash support that is expected to be received on a regular basis. Yes No Yes No

MAGI Based Methodologies MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-13-0043 System-Derived SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Resource Test There is no resource test applied to eligibility groups that use MAGI-based methodologies. D. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Methodologies Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID New User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 The state will apply the methodologies as described below, and consistent with 42 CFR 435.601, 435.602, and 435.831.

A. Basic Financial Methodology 1. The state applies the income and resource methodologies of the SSI program when determining eligibility for a population based on age (65 or older) or having blindness or a disability, with the exceptions described below in B. through G. 2. The state applies the ţnancial methodologies of either the SSI program or the AFDC program in eſect as of July 16, 1996 (whichever is most closely related) when determining eligibility for a population based on age (as a child), pregnancy, or status as a caretaker relative, with the exceptions described below in B. through G. B. Use of Less Restrictive Methodologies 1. The state elects to apply income and/or resources methodologies that are less restrictive than those used under the cash assistance programs, in accordance with 42 CFR 435.601(d). 2. The less restrictive income and resource methodologies are described on the RU for each applicable eligibility group.

Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID New User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Financial Responsibility of Relatives 1. In determining ţnancial eligibility for an individual, the state does not include income and resources from anyone other than the individual's spouse, and for individuals under age 21 or who have blindness or disability, the individual's parent. a.The state includes the income and resources of a spouse or parent only when they are living with the individual in the same household, except as follows: i. In the case of spouses who are age 65 or older or who have blindness or disability and who share the same room in a Medicaid institution, the state: ii. Where applicable, the state determines income and resource eligibility consistent with the spousal impoverishment rules of section 1924 of the Act, as described in the Resource Assessment and Eligibility reviewable unit. b. In the case of individuals under age 21 for whom AFDC is the most closely related cash assistance program, the income and resources of parents and spouses are included only if the individual would have been considered a dependent under the state's approved AFDC state plan in eſect as of July 16, 1996. (1) Considers these couples either as living together or as living separately for the purpose of counting income and resources, whichever is more advantageous to the couple. (2) Considers these couples as living separately for the purpose of counting income and resources.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID New User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 D. Family Size 1. The family size of an individual for whom the SSI income and resource methodologies are used (as described in section A) includes the persons identiţed below: a. The individual applying, or b. If the individual lives together with his or her spouse, the individual applying and the spouse, or c. If the individual lives together with his or her parent(s) and the individual is under 21 or has blindness or a disability, the individual applying and the parent(s). 2. The family size of an individual for whom the AFDC income and resource methodologies are used (as described in section A.), includes the persons who would have been included in the family under the state's July 16, 1996 AFDC state plan, except where the state has elected to use the MAGI-like methodologies (as described in section E). 3. The state deţnes family size for one or more of the following FPL eligibility groups to include others beyond those identiţed in D.1. and D.2. Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID New User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 E. Use of MAGI-like Methodologies 1. The state uses MAGI-like methodologies for one or more populations for whom the most closely related cash assistance program would be the AFDC program in eſect as of July 16, 1996. Yes No

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID New User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 F. Countable Income Deductions for the Medically Needy In determining countable income for individuals who are age 65 or older or who have blindness or a disability, the state deducts: 1. Amounts that would be deducted in determining eligibility under SSI. 2. The highest amounts that would be deducted in determining eligibility for optional state supplements if these supplements are paid to all individuals who are receiving SSI or would be eligible for SSI except for their income.

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID New User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 G. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-01-019 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 A. Income Level Used 1. The state employs a single income level for the medically needy. 2. The income level varies based on diſerences between shelter costs in urban and rural areas. 3. The level used is: Household size Standard 3 $658.00 4 $792.00 1 $525.00 2 $525.00 5 $925.00 6 $1058.00 7 $1192.00 8 $1317.00 9 $1383.00 10 $1450.00 11 $1508.00 12 $1558.00 The state uses an additional incremental amount for larger household sizes. The dollar amounts increase automatically each year Yes No Yes No Yes No

Household size Standard 13 $1608.00 14 $1658.00 15 $1700.00 16 $1742.00

Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-01-019 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Basis for Income Level 1. Minimum Income Level The minimum income level for this eligibility group is the lower of the state’s July 1996 AFDC payment standard or the state’s income standard for the Parents and Other Caretaker Relatives eligibility group. 2. Maximum Income Level The maximum income level for this eligibility group is 133 1/3 percent of the higher of the state's 1996 AFDC payment standard or the state's income standard for the Parents and Other Caretaker Relatives eligibility group.

Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-01-019 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Standards Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-92-02 and MT-93-23 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 If countable income exceeds the income standard, the state must deduct from income medical expenses incurred by the individual or family or ţnancially responsible relatives that are not subject to payment by a third party, in accordance with 42 CFR 435.831 and 42 CFR 435.121. A. Budget Periods Income in excess of the appropriate income standard is considered available for payment of medical or remedial care expenses in budget periods that do not exceed six months. 1. In determining income eligibility, countable income is reduced by the amount of incurred medical or remedial care expenses during the budget period speciţed below: 2. The state includes part or all of the retroactive period in the budget period. a. One budget period of: i. 6 months ii. 5 months iii. 4 months iv. 3 months v. 2 months vi. 1 month b. More than one budget period, as described below: Yes No

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-92-02 and MT-93-23 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Types of Eligible Expenses 1. In determining incurred expenses to be deducted from income, the state includes: a. Medicare, Medicaid, and other health insurance premiums and enrollment fees. b. Cost sharing, including copayments, coinsurance, and deductibles, imposed by Medicare, Medicaid or other health insurance. c. Expenses for necessary medical and remedial services recognized by state law but not included in the state plan. d. Expenses for necessary medical and remedial services included in the state plan, including those that exceed limitations on the amount, duration, and scope of services. 2. The state also includes medical institutional expenses projected to the end of the budget period at the Medicaid reimbursement rate. 3. Incurred expenses subject to payment by a third party are not deducted unless the third party is a public program (other than Medicaid) of a state and the program is ţnanced by the state. Yes No

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-92-02 and MT-93-23 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Timeframe of Deduction of Expenses In determining incurred expenses to be deducted from income, the state deducts: 1. For retroactive budget periods and a budget period that includes both retroactive and prospective budget, the state deducts: a. Eligible expenses incurred during the budget period, whether paid or unpaid. b. Payments made during the budget period on eligible expenses incurred at any time prior to the budget period, if not previously deducted in establishing eligibility. c. Unpaid eligible expenses, which have not been deducted previously in establishing eligibility, and were incurred: 2. For prospective budget period(s), the state deducts: a. Eligible expenses incurred during the budget period, whether paid or unpaid. b. Payments made during the budget period on eligible expenses incurred at any time prior to the budget period, if not previously deducted in establishing eligibility. c. Unpaid eligible expenses that are carried over from the prior budget period and have not been deducted previously in establishing eligibility. i. At any time prior to the budget period. ii. Prior to the third month before the month of application, but no earlier than: iii. No earlier than the third month before the month of application.

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-92-02 and MT-93-23 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 D. Order of Deduction of Expenses Incurred medical or remedial care expenses are deducted in the following order: a. Premiums, deductibles, coinsurance and co-payments. b. Expenses for necessary medical or remedial care services that are recognized under state law but not included in the State Plan. c. Expenses for necessary medical or remedial care services that are included in the state Plan that exceed agency limitations on amount, duration, or scope of services. d. Expenses for necessary medical or remedial care services that are included in the state Plan that are within the agency limitations on amount, duration, or scope of services. 1. By the type of service, in the following order: 2. In chronological order by the date of the service, or the date cost sharing payments are due. 3. In chronological order by the date the bill is submitted to the state by the individual.

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-92-02 and MT-93-23 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 E. Reasonable Limitations The state sets reasonable limits on the amount to be deducted for expenses. Yes No

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-92-02 and MT-93-23 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 F. Spenddown Payments Made by Individuals The state permits individuals to pay-in their spenddown liability. 1. The state provides all individuals with the option to pay-in their spenddown or to use incurred expenses for spenddown. 2. The state disburses to the individual amounts for services not covered under the state plan. 3. The state refunds unused pay-in amounts, as follows: Yes No a. The state refunds unused pay-in amounts on a case-by-case basis. b. The state applies unused pay-in amounts toward spenddown liability in a subsequent budget period on a case-by-case basis.

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-92-02 and MT-93-23 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 G. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Resource Level MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-97-004 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 A. Medically Needy Resource Level Structure 1. The state employs a single resource level for the medically needy. 2. The resource level is equal to or higher than the lowest resource standard used under the most closely related cash assistance program.

Medically Needy Resource Level MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-97-004 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Resource Level Used The level used is: Household size Standard 1 $3000.00 2 $3000.00 3 $3000.00 4 $3000.00 5 $3000.00 6 $3000.00 7 $3000.00 8 $3000.00 9 $3000.00 10 $3000.00 The state uses an additional incremental amount for larger household sizes. Yes No

Medically Needy Resource Level MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-97-004 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Additional Information (optional)

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-19-0005 System-Derived SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children NEW Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneţciaries NEW

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW Working Individuals under 1619(b) NEW Qualiţed Medicare Beneţciaries APPROVED Qualiţed Disabled and Working Individuals NEW Speciţed Low Income Medicare Beneţciaries APPROVED Qualifying Individuals APPROVED

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-19-0005 System-Derived SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group CONVERTED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A Yes No

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Qualiţed Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Individuals with income equal to or less than 100% of the FPL, who are entitled to Medicare Part A, and who qualify for Medicare cost-sharing. Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 The state covers the mandatory qualiţed Medicare beneţciaries group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are entitled to hospital insurance beneţts under part A of title XVIII (Medicare Part A), including individuals who have purchased a premium to enroll in Part A.

2. Have income and resources at or below the standard for this group.

Qualiţed Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payments are excluded as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of disregard: Description: Contract for Deed A contract for deed, for which the provisions of the contract are being met, and which contains a provision for at least annual payments, will be excluded as a resource so long as the provisions of the contract are being met, including scheduled payments. Yes No Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used: Yes No General resource disregard:

Name of disregard: Description: Value of a Life Estate The value of a life estate will be excluded as a resource if the life estate is being used to produce income consistent with the fair market value of the property. Income will be considered consistent with the fair market value of the property if the net income produced is at least 6% of the fair market value of the property. Value of First Resource Purchased with Excluded Native American Funds The value of the ţrst resource purchased with excluded Native American funds, as long as the purchase is clearly identiţable as being made with excluded funds. This would include the ţrst transfer of excluded funds into a non-excluded account, so long as the excluded funds remained clearly identiţable. Description: All funds (including interest) contained in an Individual Development Account (IDA) are excluded as a Resource. Description: The disregard shall apply only to amounts contributed to the account during the individual's enrollment in the section 1902(a) (10)(A)(ii)(XIII) category, and any interest and earnings accrued by the account during and subsequent to such enrollment. No additional deposits into the account are permitted once the individual is no longer enrolled in the eligibility category described at section 1902(a)(10)(A)(ii)(XIII) of the Act. Actions involving the accounts are subject to standard eligibility rules relating to resources (e.g., a transfer from the account for less than fair market value would be subject to transfer-of-asset rules). The state uses a less restrictive methodology with respect to the treatment of resources set aside in speciţed types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Resources set aside in Independence/Freedom accounts A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Qualiţed Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Income Standard Used The amount of the income standard for this group is 100% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-beneţt low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment of co-insurance and deductibles for Medicare Parts A, B and C and payment for the premiums for Medicare Parts A and B.

Medical assistance begins the ţrst day of the month following the month in which the individual is determined to qualify for this eligibility group.

Qualiţed Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Speciţed Low Income Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Individuals with income above 100% and below 120% of the FPL who are entitled to Medicare Part A, who qualify for payment of Medicare Part B premiums. Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 The state covers the mandatory speciţed low income Medicare beneţciaries group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Would qualify as Qualiţed Medicare Beneţciaries (described in section 1905(p)(1) of the Act), except that their income exceeds the income level for that eligibility group.

2. Have income below the income standard and resources at or below the resource standard for this group.

Speciţed Low Income Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payment are excluded as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of disregard: Description: Contract for Deed A contract for deed, for which the provisions of the contract are being met, and which contains a provision for at least annual payments, will be excluded as a resource so long as the provisions of the contract are being met, including scheduled payments. Yes No Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used: Yes No General resource disregard:

Name of disregard: Description: Value of a Life Estate The value of a life estate will be excluded as a resource if the life estate is being used to produce income consistent with the fair market value of the property. Income will be considered consistent with the fair market value of the property if the net income produced is at least 6% of the fair market value of the property. Value of First Resource Purchased with Excluded Native American Funds The value of the ţrst resource purchased with excluded Native American funds, as long as the purchase is clearly identiţable as being made with excluded funds. This would include the ţrst transfer of excluded funds into a non-excluded account, so long as the excluded funds remained clearly identiţable. Description: All funds (including interest) contained in an Individual Development Account (IDA) are excluded as a Resource. Description: The disregard shall apply only to amounts contributed to the account during the individual's enrollment in the section 1902(a) (10)(A)(ii)(XIII) category, and any interest and earnings accrued by the account during and subsequent to such enrollment. No additional deposits into the account are permitted once the individual is no longer enrolled in the eligibility category described at section 1902(a)(10)(A)(ii)(XIII) of the Act. Actions involving the accounts are subject to standard eligibility rules relating to resources (e.g., a transfer from the account for less than fair market value would be subject to transfer-of-asset rules). The state uses a less restrictive methodology with respect to the treatment of resources set aside in speciţed types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Resources set aside in Independence/Freedom accounts A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Speciţed Low Income Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Income Standard Used Family income must be above 100% FPL and below 120% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-beneţt low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment for Medicare Part B premiums.

Speciţed Low Income Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Individuals with income at or above 120% and below 135% of the FPL who are entitled to Medicare Part A, who qualify for payment of Medicare Part B premiums. Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 The state covers the mandatory qualifying individuals group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet all of the following criteria: 1. Would qualify as Qualiţed Medicare Beneţciaries (described in section 1905(p)(1) of the Act), except that their income exceeds the income level for that eligibility group.

2. Are not otherwise eligible for Medicaid under the state plan.

3. Have income below the income standard and resources at or below the resource standard for this group.

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payments are excluded as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of disregard: Description: Contract for Deed A contract for deed, for which the provisions of the contract are being met, and which contains a provision for at least annual payments, will be excluded as a resource so long as the provisions of the contract are being met, including scheduled payments. Yes No Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used: Yes No General resource disregard:

Name of disregard: Description: Value of a Life Estate The value of a life estate will be excluded as a resource if the life estate is being used to produce income consistent with the fair market value of the property. Income will be considered consistent with the fair market value of the property if the net income produced is at least 6% of the fair market value of the property. Value of First Resource Purchased with Excluded Native American Funds The value of the ţrst resource purchased with excluded Native American funds, as long as the purchase is clearly identiţable as being made with excluded funds. This would include the ţrst transfer of excluded funds into a non-excluded account, so long as the excluded funds remained clearly identiţable. Description: All funds (including interest) contained in an Individual Development Account (IDA) are excluded as a Resource. Description: The disregard shall apply only to amounts contributed to the account during the individual's enrollment in the section 1902(a) (10)(A)(ii)(XIII) category, and any interest and earnings accrued by the account during and subsequent to such enrollment. No additional deposits into the account are permitted once the individual is no longer enrolled in the eligibility category described at section 1902(a)(10)(A)(ii)(XIII) of the Act. Actions involving the accounts are subject to standard eligibility rules relating to resources (e.g., a transfer from the account for less than fair market value would be subject to transfer-of-asset rules). The state uses a less restrictive methodology with respect to the treatment of resources set aside in speciţed types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Resources set aside in Independence/Freedom accounts A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Income Standard Used Family income must be at or above 120% FPL and below 135% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-beneţt low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment for Medicare Part B premiums.

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 F. Additional Information (optional)

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-19-0005 System-Derived SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 A. Options for Coverage The state provides Medicaid to speciţed optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper-based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classiţcations of Individuals under Age 21 CONVERTED Children with Non-IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents NEW Optional Targeted Low Income Children CONVERTED Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer APPROVED Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Yes No

Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance APPROVED Individuals Eligible for Cash Except for Institutionalization APPROVED Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneţciaries NEW Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability-Related Poverty Level NEW Work Incentives APPROVED Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-19-0005 System-Derived SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Medically Needy Options for Coverage The state provides Medicaid to speciţed groups of individuals who are medically needy. The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Pregnant Women APPROVED Medically Needy Children under Age 18 APPROVED Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Protected Medically Needy Individuals Who Were Eligible in 1973 NEW 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Reasonable Classiţcations of Individuals under Age 21 APPROVED Medically Needy Parents and Other Caretaker Relatives NEW Yes No

Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Populations Based on Age, Blindness or Disability APPROVED

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-19-0005 System-Derived SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Individuals who are eligible for but not receiving federal cash assistance or an optional state supplement. Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 The state covers the optional Individuals Eligible for but Not Receiving Cash Assistance eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Meet the eligibility requirements of at least one of the following cash assistance programs: 2. Do not receive cash assistance under these programs. a. SSI b. Optional State Supplement c. AFDC

Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. 2. The state covers the following populations: Yes No a. Individuals age 65 or older b. Individuals who have blindness c. Individuals who have a disability d. All children under a speciţed age limit: e. Reasonable classiţcations of children f. Parents and other caretaker relatives g. Pregnant women h. Other population

Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Financial Methodologies 1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, SSI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payment are excluded as income. 4. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of disregard: Description: Contract for Deed A contract for deed, for which the provisions of the contract are being met, and which contains a provision for at least annual payments, will be excluded as a resource so long as the provisions of the contract are being met, including scheduled payments. Yes No Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used: Yes No General resource disregard:

Name of disregard: Description: Value of a Life Estate The value of a life estate will be excluded as a resource if the life estate is being used to produce income consistent with the fair market value of the property. Income will be considered consistent with the fair market value of the property if the net income produced is at least 6% of the fair market value of the property. Value of First Resource Purchased with Excluded Native American Funds The value of the ţrst resource purchased with excluded Native American funds, as long as the purchase is clearly identiţable as being made with excluded funds. This would include the ţrst transfer of excluded funds into a non-excluded account, so long as the excluded funds remained clearly identiţable. Description: All funds (including interest) contained in an Individual Development Account (IDA) are excluded as a Resource. Description: The disregard shall apply only to amounts contributed to the account during the individual's enrollment in the section 1902(a) (10)(A)(ii)(XIII) category, and any interest and earnings accrued by the account during and subsequent to such enrollment. No additional deposits into the account are permitted once the individual is no longer enrolled in the eligibility category described at section 1902(a)(10)(A)(ii)(XIII) of the Act. Actions involving the accounts are subject to standard eligibility rules relating to resources (e.g., a transfer from the account for less than fair market value would be subject to transfer-of-asset rules). The state uses a less restrictive methodology with respect to the treatment of resources set aside in speciţed types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Resources set aside in Independence/Freedom accounts A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 D. Income Standard Used The income standard used is the standard of the most closely related cash assistance program. E. Resource Standard Used The resource standard used is the standard of the most closely related cash assistance program.

Individuals Eligible for but Not Receiving Cash Assistance MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Individuals who would be eligible for federal cash assistance or an optional state supplement, except for institutionalization. Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 The state covers the optional Individuals Eligible for Cash Except for Institutionalization eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria:

1. Are in a medical institution.

2. Would meet the eligibility requirements for at least one of the following cash assistance programs, but for the lower income standards used to determine eligibility for institutionalized individuals: a. SSI b. Optional State Supplement c. AFDC

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. Yes No

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Financial Methodologies 1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, SSI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 3. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payment are excluded as income. 4. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of disregard: Description: Contract for Deed A contract for deed, for which the provisions of the contract are being met, and which contains a provision for at least annual payments, will be excluded as a resource so long as the provisions of the contract are being met, including scheduled payments. Yes No Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used: Yes No General resource disregard:

Name of disregard: Description: Value of a Life Estate The value of a life estate will be excluded as a resource if the life estate is being used to produce income consistent with the fair market value of the property. Income will be considered consistent with the fair market value of the property if the net income produced is at least 6% of the fair market value of the property. Value of First Resource Purchased with Excluded Native American Funds The value of the ţrst resource purchased with excluded Native American funds, as long as the purchase is clearly identiţable as being made with excluded funds. This would include the ţrst transfer of excluded funds into a non-excluded account, so long as the excluded funds remained clearly identiţable. Description: All funds (including interest) contained in an Individual Development Account (IDA) are excluded as a Resource. Description: The disregard shall apply only to amounts contributed to the account during the individual's enrollment in the section 1902(a) (10)(A)(ii)(XIII) category, and any interest and earnings accrued by the account during and subsequent to such enrollment. No additional deposits into the account are permitted once the individual is no longer enrolled in the eligibility category described at section 1902(a)(10)(A)(ii)(XIII) of the Act. Actions involving the accounts are subject to standard eligibility rules relating to resources (e.g., a transfer from the account for less than fair market value would be subject to transfer-of-asset rules). The state uses a less restrictive methodology with respect to the treatment of resources set aside in speciţed types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Resources set aside in Independence/Freedom accounts A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 D. Income Standard Used The income standard used is the standard of the most closely related cash assistance program. E. Resource Standard Used The resource standard used is the standard of the most closely related cash assistance program.

Individuals Eligible for Cash Except for Institutionalization MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 F. Additional Information (optional)

Eligibility Groups - Options for Coverage Work Incentives MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Individuals with a disability with income below 250% of the FPL, who would qualify for SSI except for earned income. Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT15-0016, 06-005, 01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 The state covers the optional Work Incentives eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Have earned income. 2. Meet the SSI deţnition of disability, but for earned income. 3. Meet income and resource standards following a two-step process, which includes: a. Step One - A comparison of family net income to 250% FPL; and b. Step Two - A comparison of individual net income and resources to the SSI standards, excluding earned income.

Work Incentives MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT15-0016, 06-005, 01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Step One Financial Methodologies and Income Test 1. Financial methodologies a. SSI methodologies are used in calculating family income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payment are excluded as income. 2. Income Test Family net income must be less than 250% FPL. Please refer as necessary to Non-MAGI Methodologies for the deţnition of family size. Yes No Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used:

Work Incentives MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT15-0016, 06-005, 01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Step Two Financial Methodologies and Income/Resource Test 1. Financial methodologies a. SSI methodologies are used in calculating income and resources, except that earned income is not counted. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payment are excluded as income. c. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of disregard: Description: Contract for Deed A contract for deed, for which the provisions of the contract are being met, and which contains a provision for at least annual payments, will be excluded as a resource so long as the provisions of the contract are being met, including scheduled payments. Yes No Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used: Yes No General resource disregard:

Name of disregard: Description: Value of a Life Estate The value of a life estate will be excluded as a resource if the life estate is being used to produce income consistent with the fair market value of the property. Income will be considered consistent with the fair market value of the property if the net income produced is at least 6% of the fair market value of the property. Value of First Resource Purchased with Excluded Native American Funds The value of the ţrst resource purchased with excluded Native American funds, as long as the purchase is clearly identiţable as being made with excluded funds. This would include the ţrst transfer of excluded funds into a non-excluded account, so long as the excluded funds remained clearly identiţable. Description: All funds (including interest) contained in an Individual Development Account (IDA) are excluded as a Resource. Description: Exclude the value of all retirement accounts while the account owner is receiving coverage under section 1902(a)(10)(A)(ii)(XIII) of the Act. For individuals enrolled in the eligibility category described at section 1902(a)(10)(A)(ii)(XIII) of the Act, the following resource methodology applies: -A resource disregard will apply to an account established by the beneţciary after and during the individual's enrollment in the category. The individual shall designate the account to the state Medicaid agency as his or her Independence Account. These accounts will be held separate from non-exempt resources in accounts for which prior approval has been obtained from the Department, and for which the owner authorizes regular monitoring and/or reporting including deposits, withdrawals and other information deemed necessary by the Department for the proper administration of this provision. -The Independence Account may be funded by the account owner's earned income. -There is no minimum or maximum limit to establish the account. There is no minimum or maximum limit that can be deposited to the existing account. 2. Income Test For individuals who pass Step One, in Step Two, the individual's unearned income (plus deemed income, if appropriate) must be less than one of the following income standards: 3. Resource Test The individual's resources must be less than the SSI resource standard. The state uses a less restrictive methodology with respect to the treatment of resources set aside in speciţed types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Resources set aside in Independence/Freedom accounts A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy. a. The SSI income standard. b. The income standard of the state supplement program.

Work Incentives MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT15-0016, 06-005, 01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 D. Premiums and Cost Sharing Requirements for premiums and cost sharing for this group are found in the premium and cost sharing sections of the state plan.

Work Incentives MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT15-0016, 06-005, 01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 E. Additional Information (optional) Requirements for premiums and cost sharing for this group are found in the premium and cost sharing sections as well as on page 12m of Attachment 2.6-A of the state plan.

Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Woman who are pregnant or post-partum who would qualify under the state's Pregnant Women eligibility group, except for income. Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 The state covers the Medically Needy Pregnant Women eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are pregnant or post-partum, as deţned in 42 CFR 435.4. 2. Would qualify under the Pregnant Women eligibility group, except for income. 3. Are not otherwise eligible for categorically needy coverage under the state plan. 4. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Financial Methodologies 1. The ţnancial methodology used is: 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: General Income disregard $100 of total net countable income per household per month. Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payment are excluded as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No General income disregard: Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used: Yes No General resource disregard:

Name of disregard: Description: Contract for Deed A contract for deed, for which the provisions of the contract are being met, and which contains a provision for at least annual payments, will be excluded as a resource so long as the provisions of the contract are being met, including scheduled payments. Value of a Life Estate The value of a life estate will be excluded as a resource if the life estate is being used to produce income consistent with the fair market value of the property. Income will be considered consistent with the fair market value of the property if the net income produced is at least 6% of the fair market value of the property. Value of First Resource Purchased with Excluded Native American Funds The value of the ţrst resource purchased with excluded Native American funds, as long as the purchase is clearly identiţable as being made with excluded funds. This would include the ţrst transfer of excluded funds into a non-excluded account, so long as the excluded funds remained clearly identiţable. Description: All funds (including interest) contained in an Individual Development Account (IDA) are excluded as a Resource. Description: The disregard shall apply only to amounts contributed to the account during the individual's enrollment in the section 1902(a) (10)(A)(ii)(XIII) category, and any interest and earnings accrued by the account during and subsequent to such enrollment. No additional deposits into the account are permitted once the individual is no longer enrolled in the eligibility category described at section 1902(a)(10)(A)(ii)(XIII) of the Act. Actions involving the accounts are subject to standard eligibility rules relating to resources (e.g., a transfer from the account for less than fair market value would be subject to transfer-of-asset rules). The state uses a less restrictive methodology with respect to the treatment of resources set aside in speciţed types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Resources set aside in Independence/Freedom accounts A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. D. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU. E. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is deţned in the Handling of Excess Income (Spenddown) RU.

Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 F. Additional Information (optional) Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Children under age 18 who would qualify under the state's categorically needy eligibility groups, except for income. Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 The state covers the Medically Needy Children under Age 18 eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 18. 2. Would qualify as categorically needy, except for income. 3. Are not otherwise eligible for categorically needy coverage under the state plan. 4. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Financial Methodologies 1. The ţnancial methodology used is: 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: General Income disregard $100 of total net countable income per household per month. Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payment are excluded as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No General income disregard: Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used: Yes No General resource disregard:

Name of disregard: Description: Name of disregard: Description: Contract for Deed A contract for deed, for which the provisions of the contract are being met, and which contains a provision for at least annual payments, will be excluded as a resource so long as the provisions of the contract are being met, including scheduled payments. Value of a Life Estate The value of a life estate will be excluded as a resource if the life estate is being used to produce income consistent with the fair market value of the property. Income will be considered consistent with the fair market value of the property if the net income produced is at least 6% of the fair market value of the property. Value of First Resource Purchased with Excluded Native American Funds The value of the ţrst resource purchased with excluded Native American funds, as long as the purchase is clearly identiţable as being made with excluded funds. This would include the ţrst transfer of excluded funds into a non-excluded account, so long as the excluded funds remained clearly identiţable. Description: All funds (including interest) contained in an Individual Development Account (IDA) are excluded as a Resource. Description: The disregard shall apply only to amounts contributed to the account during the individual's enrollment in the section 1902(a) (10)(A)(ii)(XIII) category, and any interest and earnings accrued by the account during and subsequent to such enrollment. No additional deposits into the account are permitted once the individual is no longer enrolled in the eligibility category described at section 1902(a)(10)(A)(ii)(XIII) of the Act. Actions involving the accounts are subject to standard eligibility rules relating to resources (e.g., a transfer from the account for less than fair market value would be subject to transfer-of-asset rules). The state uses a less restrictive methodology with respect to the treatment of resources set aside in speciţed types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Resources set aside in Independence/Freedom accounts A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. D. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU. E. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is deţned in the Handling of Excess Income (Spenddown) RU.

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 F. Additional Information (optional)

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Reasonable Classiţcations of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 One or more reasonable classiţcations of individuals under age 21 who do not qualify as categorically needy. Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 The state covers the optional Medically Needy Reasonable Classiţcations of Individuals under Age 21 eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria:

1. Are under age 21, or a lower age, as speciţed in section C. 2. Would not qualify under the Medically Needy Children under Age 18 eligibility group (42 CFR 435.301) 3. Are not otherwise eligible for categorically needy coverage under the state plan.

4. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Reasonable Classiţcations of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Individuals Covered The state covers the following populations: 1. All children under a speciţed age limit: i. Under age 21 ii. Under age 20 iii. Under age 19 2. Reasonable classiţcations of children

Medically Needy Reasonable Classiţcations of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Financial Methodologies 1. The state uses the same ţnancial methodology for all individuals covered. 2. The ţnancial methodology used is: 3. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: General Income disregard $100 of total net countable income per household per month. Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payment are excluded as income. 4. Less restrictive methodologies are used in calculating countable resources. Yes No a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No General income disregard: Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used: Yes No

The less restrictive resource methodologies are: Name of disregard: Description: Contract for Deed A contract for deed, for which the provisions of the contract are being met, and which contains a provision for at least annual payments, will be excluded as a resource so long as the provisions of the contract are being met, including scheduled payments. Value of a Life Estate The value of a life estate will be excluded as a resource if the life estate is being used to produce income consistent with the fair market value of the property. Income will be considered consistent with the fair market value of the property if the net income produced is at least 6% of the fair market value of the property. Value of First Resource Purchased with Excluded Native American Funds The value of the ţrst resource purchased with excluded Native American funds, as long as the purchase is clearly identiţable as being made with excluded funds. This would include the ţrst transfer of excluded funds into a non-excluded account, so long as the excluded funds remained clearly identiţable. Description: All funds (including interest) contained in an Individual Development Account (IDA) are excluded as a Resource. Description: The disregard shall apply only to amounts contributed to the account during the individual's enrollment in the section 1902(a) (10)(A)(ii)(XIII) category, and any interest and earnings accrued by the account during and subsequent to such enrollment. No additional deposits into the account are permitted once the individual is no longer enrolled in the eligibility category described at section 1902(a)(10)(A)(ii)(XIII) of the Act. Actions involving the accounts are subject to standard eligibility rules relating to resources (e.g., a transfer from the account for less than fair market value would be subject to transfer-of-asset rules). General resource disregard: The state uses a less restrictive methodology with respect to the treatment of resources set aside in speciţed types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Resources set aside in Independence/Freedom accounts A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Medically Needy Reasonable Classiţcations of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 D. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. E. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU. F. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is deţned in the Handling of Excess Income (Spenddown) RU.

Medically Needy Reasonable Classiţcations of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID MT-15-0016,06-005,01-001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 G. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Individuals who are age 65 or older or who have blindness or a disability who do not qualify as categorically needy. Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID 150016,09027,06005,01001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 The state covers the optional Medically Needy Populations Based on Age, Blindness or Disability eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1.Meet at least one of the following: a. Are age 65 or older;

b. Have blindness; or

c. Have a disability. 2. Are not otherwise eligible for categorically needy coverage under the state plan. 3. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID 150016,09027,06005,01001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 B. Individuals Covered The state covers the following populations: 1. Individuals age 65 or older 2. Individuals with blindness 3. Individuals who have a disability

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID 150016,09027,06005,01001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 C. Financial Methodologies 1. The state uses the same ţnancial methodology for all individuals covered. 2. The ţnancial methodology used is: a. SSI methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: General Income disregard $100 of total net countable income per household per month. Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payment are excluded as income. c. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Yes No Yes No General income disregard: Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used: Yes No

Name of disregard: Description: Contract for Deed A contract for deed, for which the provisions of the contract are being met, and which contains a provision for at least annual payments, will be excluded as a resource so long as the provisions of the contract are being met, including scheduled payments. Value of a Life Estate The value of a life estate will be excluded as a resource if the life estate is being used to produce income consistent with the fair market value of the property. Income will be considered consistent with the fair market value of the property if the net income produced is at least 6% of the fair market value of the property. Value of First Resource Purchased with Excluded Native American Funds The value of the ţrst resource purchased with excluded Native American funds, as long as the purchase is clearly identiţable as being made with excluded funds. This would include the ţrst transfer of excluded funds into a non-excluded account, so long as the excluded funds remained clearly identiţable. Description: All funds (including interest) contained in an Individual Development Account (IDA) are excluded as a Resource. Description: The disregard shall apply only to amounts contributed to the account during the individual's enrollment in the section 1902(a)(10)(A)(ii)(XIII) category, and any interest and earnings accrued by the account during and subsequent to such enrollment. No additional deposits into the account are permitted once the individual is no longer enrolled in the eligibility category described at section 1902(a)(10)(A)(ii)(XIII) of the Act. Actions involving the accounts are subject to standard eligibility rules relating to resources (e.g., a transfer from the account for less General resource disregard: The state uses a less restrictive methodology with respect to the treatment of resources set aside in speciţed types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Resources set aside in Independence/Freedom accounts

than fair market value would be subject to transfer-of-asset rules). A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID 150016,09027,06005,01001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 D. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID 150016,09027,06005,01001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 E. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID 150016,09027,06005,01001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 F. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is deţned in the Handling of Excess Income (Spenddown) RU.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0001O | MT-20-0005 Package Header Package ID MT2020MS0001O Submission Type OŰcial Approval Date 9/25/2020 Superseded SPA ID 150016,09027,06005,01001 User-Entered SPA ID MT-20-0005 Initial Submission Date 6/30/2020 Eſective Date 4/1/2020 G. Additional Information (optional)

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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 OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 9/29/2020 11:33 AM EDT

Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: 20-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, MD 21244-1850 Financial Management Group Ms. Marie Matthews State Medicaid Director Department of Public Health & Human Services P.O. Box 4210 Helena, MT 59604 Re: Montana 20-0015 Dear Ms. Matthews: We have reviewed the proposed amendment to Attachment 4.19-D of your Medicaid State plan submitted under transmittal number (TN) 20-0015. Effective for services on or after July 1, 2020, this amendment updates the fee schedule for Psychiatric Residential Treatment Facilities (PRTF) for state fiscal year 2020. We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30) and 1903(a) and of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We are pleased to inform you that Medicaid State plan amendment TN 20-0015 is approved effective July 1, 2020. The HCFA-179 (CMS-179) and the amended plan pages are attached. If you have any questions, please contact Christine Storey at (303) 844-7044. Sincerely, Rory Howe Acting Director For September 29, 2020

FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 | TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 20-0015 Montana | 3. PROGRAM IDENTIFICATION: Title XIX of the | FOR: HEALTH CARE FINANCING ADMINISTRATION Social Security Act (Medicaid) | TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 07/0 1/2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One): (NEW STATE PLAN (_] AMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT

_ COMPLETE BLOCKS 6 THRU 10 IF THIS IS ANAMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 42 CFR 440 Total

42 CFR 447.203 1902(a)(30)(A) of the Social Security Act

FFY 20 (3 months) $ 45,750 FFY 21 (12 months) — $ 185,979

8. PAGE NUMBER OF THE PLAN SECTION ORATTACHMENT: __| 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable):

Attachment 4.19B; Reimbursement Service 16 4.19-D

Attachment 4.19B, Reimbursement Service 16 4.19-D Psychiatric Residential Treatment Facilities, Pages 1-3 of 3.

Psychiatric Residential Treatment Facilities, Pages 1-3 of 3.

10. SUBJECT OF AMENDMENT:

| The Attachment 4.19B Service 16 4.19-D The Psychiatric Residential Treatment Facilities State Plan is being amended to update the date of the fee schedule, effective July 1, 2020.

| |

11. GOVERNOR'S REVIEW (Check One):

(J GOVERNOR’S OFFICE REPORTED NO COMMENT X OTHER, AS SPECIFIED: (.) COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Single Agency Director Review (J NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO:

Montana Dept. of Public Health and Human Services Marie Matthews State Medicaid Director

13. TYPED NAME: Marie Matthews Attn: Mary Eve Kulawik PO Box 4210

14. TITLE: State Medicaid Director Helena, MT 59604

15. DATE SUBMITTED: = $-\X S26

FOR REGIONAL OFFICE USE ONLY 18. DATE APPROVED:

17. DATE RECEIVED:

9/29/20 ; PLAN APPROVED ~- ONE COPY ATTACHED _ 19. EFFECTIVE DATE OF APPROVED MATERIAL: 2 : 7/20 For 21. TYPED NAME: 23. 22. TITLE: Rory Howe Acting Director FMG

REMARKS: Pen and ink change authorized by state on 9/25/2020 to change 4.19-B to 4.19-D in blocks 8, 9 and 10.

‘ORM HCFA-179 (07-92)

9/29/20

9/29/20

9/29/20

Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: 20-0024 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 May 8, 2020 Marie Matthews, Medicaid & CHIP Director Montana Department of Public Health & Human Services P.O. Box 4210 Helena, MT 59604 Re: Montana State Plan Amendment (SPA) MT-20-0024 Dear Ms. Matthews: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0024. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID- 19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID- 19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency.

The State of Montana also requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is also waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. The State of Montana also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These waivers or modifications of the requirements related to SPA submission timelines, public notice, and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Montana’s Medicaid SPA Transmittal Number MT 20-0024 is approved effective March 1, 2020. Please note that the effective date for the new COVID-19 testing eligibility group described at section 1902(a)(10)(A)(ii)(XXIII) of the Act is March 18, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Barbara B. Prehmus at 303-844-7472 or by email at Barbara.prehmus@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Montana and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.05.08 08:22:38 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1, TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL MT 20-0024 Montana 3. PROGRAM IDENTIFICATION: Title XIX of the FOR: HEALTH CARE FINANCING ADMINISTRATION Social Security Act (Medicaid) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 03/01/2020

DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One):

(NEW STATE PLAN (J AMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: Section 1135 of the Social Security Act 1. Optional Group described at section 1902(a)(10)(A)(ii)(XXII]) and 1902(ss) of the Act Title XIX of the Social Security Act providing coverage for uninsured individuals

March 18, 2020-Open $810,000

2. Skilled Nursing and Intermediate Care Services Supplemental Payment

March 1-June 30, 2020 $9,956,662.25

8. PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable):

Section 7 — General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency, Pages 1-10 of 10

10. SUBJECT OF AMENDMENT:

The Montana Medicaid agency seeks to implement the policies and procedures described in the disaster relief SPA, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described.

11. GOVERNOR’S REVIEW (Check One):

(] GOVERNOR’S OFFICE REPORTED NO COMMENT X OTHER, AS SPECIFIED: [_] COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Single Agency Director Review LINO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO:

Montana Dept. of Public Health and Human Services Marie Matthews

State Medicaid Director

Attn: Mary Eve Kulawik

PO Box 4210

14. TITLE: State Medicaid Director Helena, MT 59604

Jy-k 2020

arie Viatthews

15. DATE SUBMITTED:

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: 18. DATE APPROVED:

April 27, 2020 May 8, 2020

PLAN APPROVED — ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL, OFFICIAL: March 1, 2020 Anne M. —wcosteto-s Coa Date: 2020 05.08

21. TYPED NAME: 22. TITLE:

Anne Marie Costello Deputy Director, Center for Medicaid & CHIP Services

FORM HCFA-179 (07-92)

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State/Territory: Montana 1 TN: MT 20-0024 Approval Date: _________ Supersedes TN: NEW Effective Date: 03/01/2020 Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: The changes identified below are implemented for the duration of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), unless a shorter period has been identified elsewhere in the below amendment for specific items. NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 X The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. X SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. X Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These ϬϱͬϬϴͬϮϬϮϬ

State/Territory: Montana 2 TN: MT 20-0024 Approval Date: _________ Supersedes TN: NEW Effective Date: 03/01/2020 requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). c. X Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in Montana Medicaid state plan, as described below: DPHHS will consult with I/T/U’s by standard mail or email concurrent or following the submission of an amendment or waiver to CMS. DPHHS will be available to host meetings with I/T/U’s to discuss any amendment or waiver following its submission. “I/T/U’s” mean Tribal Presidents or Tribal Chairmen from Federally recognized Tribes, the Director of the Billings Area Indian Health Service, Urban Indian Organizations, and Tribal Health Departments. Section A – Eligibility 1. X The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. Optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. This eligibility group is effective March 18, 2020. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ -or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________ 3. ___ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. ϬϱͬϬϴͬϮϬϮϬ

State/Territory: Montana 3 TN: MT 20-0024 Approval Date: _________ Supersedes TN: NEW Effective Date: 03/01/2020 Less restrictive income methodologies: Less restrictive resource methodologies: 4. ____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: 6. ____ The agency provides for an extension of the reasonable opportunity period for non-citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. ____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. 2. ____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. ϬϱͬϬϴͬϮϬϮϬ

State/Territory: Montana 4 TN: MT 20-0024 Approval Date: _________ Supersedes TN: NEW Effective Date: 03/01/2020 4. _ The agency adopts a total of ____ months (not to exceed 12 months) continuous eligibility for children under age enter age ____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. ___ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every ____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. ____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. ____ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: 2. _____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. _____ The following eligibility groups or categorical populations: N/A 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. N/A ϬϱͬϬϴͬϮϬϮϬ

State/Territory: Montana 5 TN: MT 20-0024 Approval Date: _________ Supersedes TN: NEW Effective Date: 03/01/2020 Section D – Benefits Benefits: 1. ___ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2.

The agency makes the following adjustments to benefits currently covered in the state plan: 3. _____ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Please describe. Telehealth: 5. X The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Covered Telemedicine/Telehealth Services All Montana Medicaid covered services delivered via telemedicine/telehealth are reimbursable so long as a) such services are medically necessary and clinically appropriate for delivery via telemedicine/telehealth, b) comport with the guidelines set forth in the applicable Montana Medicaid provider manual, and c) are not a service specifically required to be face-to-face as defined in the applicable Montana Medicaid provider manual. Allowable Telemedicine/Telehealth Methods and Technologies There are no specific requirements for technologies used to deliver services via telemedicine/telehealth and can be provided using: secure portal messaging, secure instant messaging, telephone conversations, and audio-visual conversations. ϬϱͬϬϴͬϮϬϮϬ

State/Territory: Montana 6 TN: MT 20-0024 Approval Date: _________ Supersedes TN: NEW Effective Date: 03/01/2020 Requirements for telemedicine/telehealth encounters • To the extent possible, providers must ensure members have the same rights to confidentiality and security as provided during traditional office visits. • Providers must follow consent and patient information protocol consistent with those followed during in person visits. • Telemedicine/telehealth does not alter the scope of practice of any health care provider; or authorize the delivery of health care services in a setting or manner not otherwise authorized by law. • Record keeping must comply with in Administrative Rules of Montana (ARM) 37.85.414. Drug Benefit: 6. X The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. Montana cover a maximum of a 90-day supply for all drugs excluding Schedule II drugs. In Montana, Schedule II drugs include most opioids, amphetamines, methylphenidate, etc. Montana will, for drugs dispensed for both 34- and 90-day refills, change the refill "too-soon" edit to allow for refills at 50%. Patients will be able to get a refill for a 34-day supply at 17 days and at 45 days for a 90-day supply. 7. X Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. Please describe the manner in which professional dispensing fees are adjusted. 9. X The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. __ Newly added benefits described in Section D are paid using the following methodology: a. __ __ Published fee schedules – ϬϱͬϬϴͬϮϬϮϬ

State/Territory: Montana 7 TN: MT 20-0024 Approval Date: _________ Supersedes TN: NEW Effective Date: 03/01/2020 Effective date (enter date of change): _____________ Location (list published location): _____________ b. _____ Other: Describe methodology here. Increases to state plan payment methodologies: 2. X The agency increases payment rates for the following services: Skilled Nursing and Intermediate Care Services a. _____ Payment increases are targeted based on the following criteria: Please describe criteria. b. Payments are increased through: i. X A supplemental payment or add-on within applicable upper payment limits: The state will issue supplemental payments to Skilled Nursing and Intermediate Care Service Facilities equivalent to $40 per day per Medicaid member effective for dates of payment March 1, 2020 through June 30, 2020. The state will not claim FFP for any amounts exceeding the applicable upper payment limit. Montana utilizes a paid claims query to determine the number of Medicaid paid bed days per facility. The query is run every 2 weeks after a payment cycle is complete, with the exception of the first run covering 3/1/2020 to 4/15/2020. This is the basis of payments. Bed days are multiplied by $40 to determine the payment. The payments are sent out via the Medicaid agency’s Business and Financial Services Division; a history-only adjustment to the claims system is completed by the agency’s Senior and Long Term Care Division staff. ii. _____ An increase to rates as described below. Rates are increased: _____ Uniformly by the following percentage: _____________ _____ Through a modification to published fee schedules – ϬϱͬϬϴͬϮϬϮϬ

State/Territory: Montana 8 TN: MT 20-0024 Approval Date: _________ Supersedes TN: NEW Effective Date: 03/01/2020 Effective date (enter date of change): _____________ Location (list published location): _____________ _____ Up to the Medicare payments for equivalent services. _____ By the following factors: Please describe. Payment for services delivered via telehealth: 3. For the duration of the emergency, the state authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid state plan; b. _____ Differ from payments for the same services when provided face to face; c. Differ from current state plan provisions governing reimbursement for telehealth; d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. _____ Other payment changes: Please describe. Section F – Post-Eligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: ϬϱͬϬϴͬϮϬϮϬ

State/Territory: Montana 9 TN: MT 20-0024 Approval Date: _________ Supersedes TN: NEW Effective Date: 03/01/2020 a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information 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 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. 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. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870. ϬϱͬϬϴͬϮϬϮϬ

Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: 2-00 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 0DUFK   Marie Matthews, Medicaid & CHIP Director Montana Department of Public Health & Human Services P.O. Box 4210 Helena, MT 59604 Re: Montana State Plan Amendment (SPA) 21-0003 Dear Ms. Matthews: We have reviewed the proposed amendment to add section 7.4.A Rescissions to State’s Disaster Relief Policies for the COVID-19 National Emergency to 0RQWDQD V 0HGLFDLG state plan, as submitted under transmittal number (TN) 21-0003. 7KLV DPHQGPHQW SURSRVHV WR UHVFLQG D WHPSRUDU\ SROLF\ SUHYLRXVO\ DSSURYHG LQ VHFWLRQ  RI WKH 0HGLFDLG 6WDWH 3ODQ WKURXJK WKH VXEPLVVLRQ RI D 0HGLFDLG 'LVDVWHU 5HOLHI 6WDWH 3ODQ $PHQGPHQW 63$  We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. Section 7.4 of the Medicaid state plan provides temporary authority and is intended to be in effect only for the duration of the COVID-19 public health emergency. Due to the temporary nature of this provision, and because the state has not yet implemented the COVID-19 testing group and no individuals have been enrolled for coverage, TN 21-0003 is approved effective March 18, 2020 pursuant to 42 CFR 430.20(b)(3). Enclosed is a copy of the CMS-179 summary form and the approved state plan page. 3OHDVH FRQWDFW %DUEDUD 3UHKPXV DW   RU E\ HPDLO DW EDUEDUDSUHKPXV#FPVKKVJRY LI \RX KDYH DQ\ TXHVWLRQV DERXW WKLV DSSURYDO 6LQFHUHO\ $OLVVD 0RRQH\ 'H%R\ 2Q %HKDOI RI $QQH 0DULH &RVWHOOR $FWLQJ 'LUHFWRU &HQWHU IRU 0HGLFDLG DQG &+,3 6HUYLFHV Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2021 03.31 10:05:40 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION OMB NO- 0938-0193 _ TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL MT 21-0003 Montana 3. PROGRAM IDENTIFICATION: Title XIX of the FOR: HEALTH CARE FINANCING ADMINISTRATION Social Security Act (Medicaid) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION 03/18/2020

DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One):

[NEW STATE PLAN [LJAMENDMENT TO BE CONSIDERED AS NEW PLAN X AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT:

1. Optional Group described at section 1902(a)(10)(A)(ii)(XXIID) and 1902(ss) of the Act providing coverage for uninsured individuals

FY 20 $0 March-+&-2026-end- of PHE--(8810000) Fy 21 $0

8. PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (if Applicable):

Section 1902(a)(10)(A)(ii)(XXIID of the Social Security Act

Section 7.4.A. Rescissions to the State’s Disaster Relief Policies for | Not applicable the COVID-19 National Emergency, Page 1 of 1

10. SUBJECT OF AMENDMENT:

Effective March 18, 2020, the agency rescinds the election at A.1. of section 7.4 (approved on May 8, 2020 in SPA Number MT-20-0024) of the state plan to furnish medical assistance to the optional eligibility group.

11. GOVERNOR’S REVIEW (Check One):

(1) GOVERNOR’S OFFICE REPORTED NO COMMENT X OTHER, AS SPECIFIED:

(] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Single Agency Director Review

LINO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL : 12 | 16. RETURN TO:

Montana Dept. of Public Health and Human Services Marie Matthews State Medicaid Director

| 13! Attn: Mary Eve Kulawik PO Box 4210 14. TITLE: State Medicaid Director Helena, MT 59604

15. DATE SUBMITTED: l 7 | FOR REGIONAL OFFICE USE ONLY ; 17. DATE RECEIVED: 18. DATE APPROVED: March 31| 2021

January 21, 2021 PLAN APPROVED — ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATUREQK REGION ALOFBICHANss2 + M. Deboy -S March 18, 2020 Deboy -S Date: 2021 09.31 21. TYPED NAME: 22. TITLE: On Behalf of Anne Marie Costello, Acting Director|

Center for Medicaid and CHIP Services

Alissa Mooney DeBoy

23. REMARKS: Pen & Ink change authorized by state on 1/26/2021 to revise the federal budget impact in Box 7 to $0 to reflect that the optional coverage group was not implemented.

FORM HCFA-179 (07-92)

State/Territory: Montana NEW TN MT 21-0003 Supersedes TN: NEW Approved_0DUFK   Effective March 18, 2020 7.4.A. Rescissions to the State’s Disaster Relief Policies for the COVID-19 National Emergency Effective March 18, 2020, the agency rescinds the election at A.1. of section 7.4 (approved on May 8, 2020 in SPA Number MT-20-0024) of the state plan to furnish medical assistance to the optional eligibility group described at section 1902(a)(10)(A)(ii)(XXIII) of the Social Security Act.

_____________________________________________________________________________ Table of Contents State/Territory Name: Montana State Plan Amendment (SPA) #: 21-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All MT - Submission Package - MT2020MS0002O - (MT-21-0004) - Eligibility CMS-10434 OMB 0938-1188 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid & CHIP Operations Group 601 East 12th Street, Suite 355 Kansas City, MO 64106-2898 Center for Medicaid & CHIP Services March 25, 2021 Marie Matthews Medicaid & CHIP Director Montana Department of Public Health and Human Services 111 North Sanders, Room 301 Helena, MT 59604 Re: Approval of State Plan Amendment MT-21-0004 Dear Marie Matthews, On January 05, 2021, the Centers for Medicare and Medicaid Services (CMS) received Montana State Plan Amendment (SPA) MT-21-0004 to integrate eligibility for the state's 1115 family planning demonstration waiver into the state's Medicaid eligibility application and eligibility determination system. This state plan amendment approves speciţc changes to modify the state’s paper and online applications to integrate eligibility for the state’s 1115 family planning demonstration waiver into the state’s Medicaid eligibility application and eligibility determination system. The changes approved are limited to inclusion of two additional questions to ensure an applicant can apply and be determined eligible for family planning coverage, as provided under Montana’s section 1115 family planning demonstration. These approved changes are added to the previously approved versions of the applications approved under SPA MT 13-0044. We approve Montana State Plan Amendment (SPA) MT-21-0004 with an eſective date(s) of January 01, 2021. If you have any questions regarding this amendment, please contact Barbara Prehmus at barbara.prehmus@cms.hhs.gov or at 303-844-7472 Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0002O | MT-21-0004 Package Header Package ID MT2020MS0002O Submission Type OŰcial Approval Date 3/25/2021 Superseded SPA ID N/A SPA ID MT-21-0004 Initial Submission Date 1/5/2021 Eſective Date N/A State Information State/Territory Name: Montana Medicaid Agency Name: Department of Public Health and Human Services Submission Component State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0002O | MT-21-0004 Package Header Package ID MT2020MS0002O Submission Type OŰcial Approval Date 3/25/2021 Superseded SPA ID N/A SPA ID MT-21-0004 Initial Submission Date 1/5/2021 Eſective Date N/A SPA ID and Eſective Date SPA ID MT-21-0004 Reviewable Unit Proposed Eſective Date Superseded SPA ID Application 1/1/2021 MT-13-044MM

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0002O | MT-21-0004 Package Header Package ID MT2020MS0002O Submission Type OŰcial Approval Date 3/25/2021 Superseded SPA ID N/A SPA ID MT-21-0004 Initial Submission Date 1/5/2021 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives Montana is integrating the state’s 1115 Plan First Demonstration Waiver (family planning at 42 CFR 435.214) into the CHIMES eligibility system. One of the eligibility requirements of the Plan First Waiver is that the woman be able to bear children/become pregnant. Therefore, DPHHS plans to add a related question to Montana’s single streamlined Medicaid application (HCS-256), the multi-program application (HCS-250), and the online application via the Self Service Portal at apply.mt.gov.

This SPA is submitted to seek approval only for the speciţc changes being made to add questions to the state’s paper and online applications to integrate family planning eligibility. Montana added the proposed changes to the previously approved versions of the applications approved under SPA MT-13-0044. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2021 $0 Second 2022 $0 Federal Statute / Regulation Citation 42 CFR 435, Subparts J and M Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0002O | MT-21-0004 Package Header Package ID MT2020MS0002O Submission Type OŰcial Approval Date 3/25/2021 Superseded SPA ID N/A SPA ID MT-21-0004 Initial Submission Date 1/5/2021 Eſective Date N/A Governor's OŰce Review No comment Comments received No response within 45 days Other

Medicaid State Plan Eligibility General Eligibility Requirements Application MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0002O | MT-21-0004 Package Header Package ID MT2020MS0002O Submission Type OŰcial Approval Date 3/25/2021 Superseded SPA ID MT-13-044MM User-Entered SPA ID MT-21-0004 Initial Submission Date 1/5/2021 Eſective Date 1/1/2021 A. MAGI Paper Application The state uses the following paper application(s) for individuals applying for coverage based on the applicable modiţed adjusted gross income (MAGI) standard. Name 2015 Single Streamlined Application (003) box unchecked, identical wording The paper application(s) has been uploaded. Document Name Date Created 2015 Single Streamlined Application (003) box unchecked, identical wording 3/16/2021 11:59 AM EDT Name HCS-250 10-2020 rework plan ţrst questions-identical wording The alternative multi-program paper application(s) has been uploaded. Document Name Date Created HCS-250 10-2020 rework plan ţrst questions-identical wording 3/16/2021 12:03 PM EDT 1. The single, streamlined application for all insurance aſordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Aſordable Care Act 2. One or more alternative single, streamlined applications developed by the state in accordance with section 1413(b)(1)(B) of the Aſordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary 3. One or more alternative applications used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single streamlined application used only for insurance aſordability programs to individuals seeking assistance only through such programs 4. Other alternative applications, provided that the agency makes readily available the single streamlined application used only for insurance aſordability programs to individuals seeking assistance only through such programs

Application MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0002O | MT-21-0004 Package Header Package ID MT2020MS0002O Submission Type OŰcial Approval Date 3/25/2021 Superseded SPA ID MT-13-044MM User-Entered SPA ID MT-21-0004 Initial Submission Date 1/5/2021 Eſective Date 1/1/2021 B. MAGI Online Application The state uses the following online application(s) for individuals applying for coverage based on the applicable MAGI standard. Name S94 Single Streamlined Application 02-23-21 Screenshots or other documentation of the online application(s) has been uploaded. Document Name Date Created S94 Single Streamlined Application 022321 3/5/2021 3:38 PM EST Name S94 Single Streamlined Application 02-23-2021 Description Online application Screenshots or other documentation of the online application(s) have been uploaded. Document Name Date Created S94 Single Streamlined Application 022321 3/1/2021 12:36 PM EST 1. The single, streamlined application for all insurance aſordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Aſordable Care Act 2. One or more alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Aſordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary 3. One or more alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single application used only for insurance aſordability programs to individuals seeking assistance only through such programs 4. Other alternative applications, provided that the agency makes readily available the single streamlined application used only for insurance aſordability programs to individuals seeking assistance only through such programs

Application MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0002O | MT-21-0004 Package Header Package ID MT2020MS0002O Submission Type OŰcial Approval Date 3/25/2021 Superseded SPA ID MT-13-044MM User-Entered SPA ID MT-21-0004 Initial Submission Date 1/5/2021 Eſective Date 1/1/2021 C. Basis Other than MAGI - Paper Application The state uses the following paper application(s) for individuals applying for coverage on a basis other than the applicable MAGI standard: The supplemental form(s) used to collect additional information has been uploaded. Name Date Created 2015 Single Streamlined Application (003) box unchecked, identical wording 3/16/2021 12:05 PM EDT Name HCS-250 10-2020 rework plan ţrst questions-identical wording This application for multiple human service programs is the same one used for applicants on the basis of the applicable MAGI standard. 1. The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary 2. One or more applications designed speciţcally to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary 3. One or more applications used to apply for multiple human service programs Yes No 4. Other alternative applications

Application MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0002O | MT-21-0004 Package Header Package ID MT2020MS0002O Submission Type OŰcial Approval Date 3/25/2021 Superseded SPA ID MT-13-044MM User-Entered SPA ID MT-21-0004 Initial Submission Date 1/5/2021 Eſective Date 1/1/2021 D. Other than MAGI - Online Application The state uses the following online application(s) for individuals applying for coverage who may be eligible on a basis other than the applicable MAGI standard: Screenshots or other documentation of the online form(s) used to the collect additional information have been uploaded Name Date Created S94 Single Streamlined Application 022321 2/25/2021 12:52 PM EST 1. The single, streamlined application developed by the Secretary or one of the alternate online forms developed by the state and approved by the Secretary, and supplemental online forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary 2. One or more application designed speciţcally to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary 3. One or more application used to apply for multiple human service programs 4. Other alternative applications

Application MEDICAID | Medicaid State Plan | Eligibility | MT2020MS0002O | MT-21-0004 Package Header Package ID MT2020MS0002O Submission Type OŰcial Approval Date 3/25/2021 Superseded SPA ID MT-13-044MM User-Entered SPA ID MT-21-0004 Initial Submission Date 1/5/2021 Eſective Date 1/1/2021 E. Additional Information (optional)

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), 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 OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 3/30/2021 10:09 AM EDT

Table of Contents

State/Territory Name: Montana State Plan Amendment (SPA) #: 22-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form 3) Approved SPA Pages

Records / Submission Packages - View All MT - Submission Package - MT2022MS0001O - (MT-22-0002-0000) - Eligibility Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions CMS-10434 OMB 0938-1188 Package Information Package ID MT2022MS0001O Program Name N/A SPA ID MT-22-0002-0000 Version Number 2 Submitted By Mary Kulawik Package Disposition Priority Code P2 Lead Division DMEP Submission Type Official State MT Region Denver, CO Package Status Approved Submission Date 3/31/2022 Approval Date 6/15/2022 12:42 PM EDT

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID N/A SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date N/A State Information State/Territory Name: Montana Medicaid Agency Name: Department of Public Health and Human Services Submission Component DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Division of Program Operations 601 E. 12th Street Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services June 15, 2022 Michael Randol Montana Medicaid and Health Services Executive Director/State Medicaid Director Department of Public Health and Human Services P.O. Box 4210 Helena, MT 59604 Re: Approval of State Plan Amendment MT-22-0002 Dear Michael Randol, On March 31, 2022, the Centers for Medicare and Medicaid Services (CMS) received Montana State Plan Amendment (SPA) MT-22-0002, in which the state proposed to increase the general income disregard for medically needy individuals from $100 to $269 per month, and to further modify the disregard consistent with Social Security Administration cost-of-living adjustments beginning in 2023 and in subsequent years. We approve Montana State Plan Amendment (SPA) MT-22-0002 with an effective date(s) of January 01, 2022. If you have any questions regarding this amendment, please contact Barbara Prehmus at barbara.prehmus@cms.hhs.gov or at 303-844-7472 Sincerely, Ruth A. Hughes Acting Director, Division of Program Operations Center for Medicaid & CHIP Services State Plan Amendment Medicaid CHIP 0 0 0

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID N/A SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date N/A SPA ID and Effective Date SPA ID MT-22-0002-0000 Reviewable Unit Proposed Effective Date Superseded SPA ID Optional Eligibility Groups 1/1/2022 MT-20-0005 Medically Needy Pregnant Women 1/1/2022 MT-20-0005 Medically Needy Children under Age 18 1/1/2022 MT-20-0005 Medically Needy Reasonable Classifications of Individuals under Age 21 1/1/2022 MT-20-0005 Medically Needy Populations Based on Age, Blindness or Disability 1/1/2022 MT-20-0005

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID N/A SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives This SPA increases the Medically Needy income disregard from the approved $100 to $269, effective January 1, 2022. The income disregard will increase annually by the Social Security Administration COLA increase. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2022 $2401300 Second 2023 $2401300 Federal Statute / Regulation Citation 1902(r)(2) of the Social Security Act Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID N/A SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other 0 0 0 0

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID N/A SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date N/A Indicate whether public comment was solicited with respect to this submission. Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited 0 0 0

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID N/A SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state This state plan amendment is likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner: Date of solicitation/consultation: Method of solicitation/consultation: 3/2/2022 Tribal Consultation letter Date of solicitation/consultation: Method of solicitation/consultation: 3/2/2022 Tribal Consultation letter States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: Date of consultation: Method of consultation: 3/2/2022 Tribal Consultation letter The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created Tribal letter Clinical Trial Med Needy Income Disregard CPC+ NAL Medicare A&B final 3-2-22-2 3/11/2022 4:15 PM EST Indicate the key issues raised (optional) Yes No Yes No The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. All Indian Health Programs All Urban Indian Organizations All Indian Tribes Access Quality Cost Payment methodology 0 0 □ □ □ □ 0 0 ~ I

Eligibility Benefits Service delivery Other issue □ □ □ □

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID MT-20-0005 System-Derived SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date 1/1/2022 A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classifications of Individuals under Age 21 CONVERTED Children with Non-IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents NEW Optional Targeted Low Income Children CONVERTED Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer APPROVED Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance APPROVED Yes No

0 0 [!] □ □ 0 [!] □ 0 [!] ii □ 0 [!] □ □ 0 [!] ~ □ 0 [!] □ □ 0 [!] □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ 0 □ 0

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for Cash Except for Institutionalization APPROVED Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneficiaries NEW Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives APPROVED Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW

□ 0 □ 0 [!] □ 0 [!] □ □ 0 [!] □ □ 0 [!] ii □ 0 [!] □ □ 0 [!] □ □ 0 [!] ■ ■ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 □ □ 0

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID MT-20-0005 System-Derived SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date 1/1/2022 B. Medically Needy Options for Coverage The state provides Medicaid to specified groups of individuals who are medically needy. The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Pregnant Women APPROVED Medically Needy Children under Age 18 APPROVED Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Protected Medically Needy Individuals Who Were Eligible in 1973 NEW 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Reasonable Classifications of Individuals under Age 21 APPROVED Medically Needy Parents and Other Caretaker Relatives NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Populations Based on Age, Blindness or Disability APPROVED Yes No

0 0 □ □ □ 0 0 0 0 0 0

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID MT-20-0005 System-Derived SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date 1/1/2022 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A

Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Woman who are pregnant or post-partum who would qualify under the state's Pregnant Women eligibility group, except for income. Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID MT-20-0005 System-Derived SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date 1/1/2022 The state covers the Medically Needy Pregnant Women eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are pregnant or post-partum, as defined in 42 CFR 435.4. 2. Would qualify under the Pregnant Women eligibility group, except for income. 3. Are not otherwise eligible for categorically needy coverage under the state plan. 4. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID MT-20-0005 System-Derived SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date 1/1/2022 B. Financial Methodologies 1. The financial methodology used is: 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: General Income disregard $269 of total net countable income per household per month. This dollar amount will be adjusted annually to reflect the SSA COLA. Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payment are excluded as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of disregard: Description: Contract for Deed A contract for deed, for which the provisions of the contract are being met, and which contains a provision for at least annual payments, will be excluded as a resource so long as the provisions of the contract are being met, including scheduled payments. a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No General income disregard: Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used: Yes No General resource disregard: 0 0 0 0 0 0

Name of disregard: Description: Value of a Life Estate The value of a life estate will be excluded as a resource if the life estate is being used to produce income consistent with the fair market value of the property. Income will be considered consistent with the fair market value of the property if the net income produced is at least 6% of the fair market value of the property. Value of First Resource Purchased with Excluded Native American Funds The value of the first resource purchased with excluded Native American funds, as long as the purchase is clearly identifiable as being made with excluded funds. This would include the first transfer of excluded funds into a non- excluded account, so long as the excluded funds remained clearly identifiable. Description: All funds (including interest) contained in an Individual Development Account (IDA) are excluded as a Resource. Description: The disregard shall apply only to amounts contributed to the account during the individual's enrollment in the section 1902(a)(10)(A)(ii)(XIII) category, and any interest and earnings accrued by the account during and subsequent to such enrollment. No additional deposits into the account are permitted once the individual is no longer enrolled in the eligibility category described at section 1902(a)(10)(A)(ii)(XIII) of the Act. Actions involving the accounts are subject to standard eligibility rules relating to resources (e.g., a transfer from the account for less than fair market value would be subject to transfer-of-asset rules). The state uses a less restrictive methodology with respect to the treatment of resources set aside in specified types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Resources set aside in Independence/Freedom accounts A beneficiary of a "qualified state long-term care insurance partnership" policy (partnership policy), as defined in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance benefit payments made to or on behalf of the individual from the partnership policy. ~ ~ ~ ~

Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID MT-20-0005 System-Derived SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date 1/1/2022 C. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. D. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU. E. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is defined in the Handling of Excess Income (Spenddown) RU.

Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID MT-20-0005 System-Derived SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date 1/1/2022 F. Additional Information (optional) Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Children under age 18 who would qualify under the state's categorically needy eligibility groups, except for income. Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID MT-20-0005 System-Derived SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date 1/1/2022 The state covers the Medically Needy Children under Age 18 eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 18. 2. Would qualify as categorically needy, except for income. 3. Are not otherwise eligible for categorically needy coverage under the state plan. 4. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID MT-20-0005 System-Derived SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date 1/1/2022 B. Financial Methodologies 1. The financial methodology used is: 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: General Income disregard $269 of total net countable income per household per month. This dollar amount will be adjusted annually to reflect the SSA COLA. Description of disregard: Census income is disregarded. Description of disregard: Interest and earnings from Independence Accounts. Name of methodology: Description: All TANF All TANF (including Tribal TANF) cash assistance payment are excluded as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of disregard: Description: Contract for Deed A contract for deed, for which the provisions of the contract are being met, and which contains a provision for at least annual payments, will be excluded as a resource so long as the provisions of the contract are being met, including scheduled payments. a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No General income disregard: Census Bureau wages are disregarded. Interest is disregarded. The following less restrictive methodologies are used: Yes No General resource disregard: 0 0 0 0 0 0

Name of disregard: Description: Value of a Life Estate The value of a life estate will be excluded as a resource if the life estate is being used to produce income consistent with the fair market value of the property. Income will be considered consistent with the fair market value of the property if the net income produced is at least 6% of the fair market value of the property. Value of First Resource Purchased with Excluded Native American Funds The value of the first resource purchased with excluded Native American funds, as long as the purchase is clearly identifiable as being made with excluded funds. This would include the first transfer of excluded funds into a non- excluded account, so long as the excluded funds remained clearly identifiable. Description: All funds (including interest) contained in an Individual Development Account (IDA) are excluded as a Resource. Description: The disregard shall apply only to amounts contributed to the account during the individual's enrollment in the section 1902(a)(10)(A)(ii)(XIII) category, and any interest and earnings accrued by the account during and subsequent to such enrollment. No additional deposits into the account are permitted once the individual is no longer enrolled in the eligibility category described at section 1902(a)(10)(A)(ii)(XIII) of the Act. Actions involving the accounts are subject to standard eligibility rules relating to resources (e.g., a transfer from the account for less than fair market value would be subject to transfer-of-asset rules). The state uses a less restrictive methodology with respect to the treatment of resources set aside in specified types of accounts. Resources set aside in an Assets for Independence Act (IDA) account Resources set aside in Independence/Freedom accounts A beneficiary of a "qualified state long-term care insurance partnership" policy (partnership policy), as defined in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance benefit payments made to or on behalf of the individual from the partnership policy. ~ ~ ~ ~

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID MT-20-0005 System-Derived SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date 1/1/2022 C. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. D. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU. E. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is defined in the Handling of Excess Income (Spenddown) RU.

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | MT2022MS0001O | MT-22-0002-0000 Package Header Package ID MT2022MS0001O Submission Type Official Approval Date 6/15/2022 Superseded SPA ID MT-20-0005 System-Derived SPA ID MT-22-0002-0000 Initial Submission Date 3/31/2022 Effective Date 1/1/2022 F. Additional Information (optional)