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

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

Preamble

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

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

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

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

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

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

State/Territory: North Carolina

(Name of State/Territory)

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

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

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

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Carmen Hooker Odom

Position/Title: Secretary

NC Department Health and Human Services Name: L.Allen Dobson, Jr. MD Position/Title: Assistant Secretary/Director

NC Division of Medical Assistance, DHHS Name: Cinnamon H. Narron

Position/Title: Coordinator, NCHC

NC Division of Medical Assistance, DHHS Name: Mark T. Benton

Position/Title: Senior Deputy Director and Chief Operating Officer, NC Division of Medical Assistance, DHHS

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

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

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

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

1.1.1

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

1.1.2.

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

1.1.3.

A combination of both of the above.

Major elements of North Carolina’s Title XXI Plan, North Carolina Health Choice for Children Program (NCHC) include:

Effective January 1, 2006, limit the eligibility for Title XXI to children age 6 through 18 with family income up to 200% of the federal poverty level and who do not qualify for Medicaid.

1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) NC state law expressly forbids any changes in the state plan until or unless the NC General Assembly has voted on the change in the plan.

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

North Carolina’s Title XXI Plan "will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20U.S.C. 1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug

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

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Approval Date: 4 Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) 523 and 527 of the Public Health Service act of 1912 (42 U.S.C. 290 dd-3 and 290-ee-3) as amended, relating to confidentiality of alcohol and drug abuse patients records; (h) Title VIII of the Civil Rights At of 1968 (42 U.S.C. 3601 et seq.), as amended, relating to non-discrimination in the sale, rental or financing of housing; (I) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and (j) the requirements of any other nondiscrimination statute(s) which may apply to the application."

1.4

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

Plan Submitted: May 14, 1998 Plan Approved: July 14, 1998 Plan Effective Date: October 1, 1998 1st Amendment Submitted: October 21, 1998 1st Amendment Approved: January 15, 1999 1st Amendment Effective: September 30, 1998 2nd Amendment Submitted: March 26, 1999 2nd Amendment Approved: June 23, 1999 2nd Amendment Effective: March 12, 1999 3rd Amendment Submitted: July 12, 1999 3rd Amendment Approved: September 30, 1999 3rd Amendment Effective: July 1, 1999 4th Amendment Submitted: August 3, 2000 4th Amendment Approved: October 19, 2000 a. Native American Cost Sharing Exemption Effective: May 1, 2000 b. Special Needs Children Effective: October 1, 2000 5th Amendment Submitted: November 21, 2000 5th Amendment Approved: February 16, 2001 5th Amendment Effective: January 1, 2001 6th Amendment Submitted: October 12, 2001 6th Amendment Approved: January 9, 2002 6th Amendment Effective: October 8, 2001

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

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Approval Date: 5

Amended Consolidated Compliance Plan Submitted: March 1, 2005 Amended Consolidated Compliance Plan Approved: June 30, 2005

7th Amendment Effective (co-payment): February 1, 2004 7th Amendment Approved: August 24, 2001

8th Amendment Submitted: February 2006

8th Amendment Effective: January 1, 2006

8th Amendment Approved: May 10, 2006

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

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Approval Date: 6 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

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

North Carolina Health Choice for Children serves the entire state. Children who are enrolled in the program reside in all 100 counties. By age groups, fewer than 100 of these children are under age 1 at any given time because the Medicaid ceiling is 185% federal poverty level, hereinafter referred to as “fpl.” (The remainder – those falling between 185% fpl and 200% fpl equals less than one percent of the population); • ages 2 to 5 years equals 19% of the population; • ages 6 to 9 equals 29% of the population; • ages 10 to 14 equals 34% of the population; • ages 15-17 equals 15% of the population and 3 % of the children are age 18.

Children age out of the program at the end of the month in which their 19th birthday occurs.

The State of North Carolina is ethnically diverse with a growing Asian and Hispanic populations. Historically, minority populations have higher rates of uninsured children. Specific outreach efforts to ethnic and racial groups are outlined in section 5. The effectiveness of these efforts can be seen in the table, “Race NCHC 2004,” below:

The Current Population Survey, March 2005 Supplement estimated the number of children under age 19 at or below 200% of poverty to be 920,000. The number of children without health insurance was estimated at 173,000 or 7.6%.

The purpose of North Carolina’s Title XXI plan is to serve as a vehicle to encourage parents to ensure that every child in the state has access to an ongoing system of preventive health care. The program is designed to provide comprehensive health care coverage for children of working families who make too much to qualify for Title XIX and too little to afford health insurance.

Here are the basic elements of North Carolina’s Title XXI Plan:

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

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Approval Date: 7 1. The plan covers uninsured children age 6 through 18 whose family incomes do not exceed 200% of the federal poverty level 2. Eligible children are enrolled in a non-entitlement program. This means that the amount of funds available to serve them determines how many can be served. 3. In the event there are insufficient funds, new enrollments will be frozen 30 days following public notice. 4. The benefits package is that provided through the North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan (also referred to as the State Employee’s Health Plan or State Employees Health Plan) with additional preventive and maintenance dental, vision and hearing benefits. Benefits for Special Needs children are provided as follows: State Employees Health Plan administers and processes claims for children’s acute medical care and other care of special needs children. Benefits for special needs children are as provided under the Medical Assistance Program except that no services for long-term care shall be provided for special needs children and except that services for respite care for special needs children are provided only under emergency circumstances. 5. Families above 150% FPL pay copayments as follows: $1 for each generic prescription; $1 for each brand name prescription for which no generic is available and $10 for each brand name prescription with an available generic; $5 for each physician visit, clinic visit, dental and optometry visit except for preventive services (for which there is no copayment); $5 for outpatient hospital visits; and a $20 copayment for unnecessary emergency room use. For those below 150% FPL, there is a copayment for prescription drugs of $1 for all generics, $1 for brand names for which no generic is available and $3 for each brand name prescription with an available generic. 6. There is an annual enrollment fee for those above 150% of the federal poverty level of $50 per child – with a $100 maximum for two or more children in the same family. 7. Existing administrative structures and delivery systems are used. 8. Extensive outreach campaigns have been conducted to ensure that eligible children are enrolled and that their health needs are met. Payment for their care has reduced some cost shifting to other payors. The state has seen some improvement in health outcomes. 9. Enrollees whose income at reenrollment increases above 200% FPL (up to 225%) are allowed to buy into the program for one year at full cost. Because this is a costly option, few families that have

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

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Approval Date: 8 selected this option.

*As defined by the State Employees Health Plan, for the emergency service definition please see: http://statehealthplan.state.nc.us/policies/PDFs/NCHC_AD0255.pdf

Prior to the implementation of NC Health Choice, there was one public-private program in the state called the “Caring Program for Children.” This program provided basic health services including well-child checkups, physician office visits, emergency room visits for illness or injury, outpatient surgery, diagnostic services, prescription drugs and a toll-free 24 hour nurse line. It did not cover inpatient hospitalization, mental health services, dental coverage, vision and hearing care. Operated through Blue Cross/Blue Shield of North Carolina (with public funds), this program was abolished on September 30, 1998, and the 6,000 – 8,000 children enrolled in the program were recommended for membership in NC Health Choice. Since the demise of the Caring Program for Children, there has been no other public/private partnership in the State.

There are several public safety net programs such as county health departments, federally qualified health centers, rural health centers, etc., that are integral components of the State’s health care delivery system. NC Health Choice works diligently to develop and maintain strong working relationships with each of these entities, in addition to numerous public and private hospitals and family practice centers.

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

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

North Carolina’s outreach program is designed on a community- by-community basis. Each of the state’s 100 counties has an outreach committee designed to identify and reach out to all uncovered children (both Medicaid and NC Health Choice) to find and enroll them.

To encourage both new and continuing Title XIX enrollment in the state of North Carolina:

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

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• Ex parte determinations are made for all children terminated from TANF or SSI for on-going Title XIX benefits to establish eligibility under other coverage groups. • Twice annually, the State requires a review of Medically Needy cases in spend-down status. • The State provides training to maternal and child care coordinators and Medicaid’s Health Check Coordinators on eligibility requirements for children's coverage groups.

The Division of Medical Assistance (DMA) publishes each year the income thresholds for Title XIX and XXI in provider bulletins to encourage providers to refer patients who may qualify to local departments of social services for application. Among the entities receiving this information are the Women, Infants and Children's nutrition program, local health departments, etc. DMA informs advocacy agencies of Title XIX and XXI income level changes annually so they may refer potential eligibles for application.

Eligibility workers are out-stationed in hospitals, Federally Qualified Health Centers, Rural Health Centers and public health agencies to accept the XIX and XXI joint application forms.

Outreach is carried out at the county level by each of the state’s 100 outreach coalitions (one for each county). They are given material on the joint Health Check (Title XIX) and NC Health Choice for Children (Title XXI) through the State coordinated outreach effort. At both the state and county levels, every effort has been made to partner with the various children’s advocacy groups, public schools, day care organizations, churches, business and industry, providers groups, etc. Links with the provider communities have also served as a direct link to uninsured patients to encourage enrollment and reenrollment in the program.

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

There no longer exists a public-private partnership program in North Carolina since the Caring Program for Children was eliminated on September 30, 1998.

Parents of children who are not eligible for public programs are

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

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Approval Date: 10 urged to find private health insurance.

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

North Carolina’s outreach program for Title XIX and XXI children is combined in its Health Check/NC Health Choice for Children outreach effort conducted through the Division of Public Health and the section that manages the Title V program. This interaction has increased awareness of, and coordination among, all three programs. One goal of the combined outreach is to remove any stigma from any publicly offered health insurance coverage for children and to assure that the child’s use of services is maximized. Currently North Carolina’s outreach effort includes wellness and prevention messages to assist enrollees in using the program in a manner that maximizes the health of the children and minimizes unnecessary costs to the state and federal governments. The benefits of NC Health Choice are benchmarked in the Health Plan for State Employees and Teachers dependents. That plan - plus vision, dental, hearing and special needs to the Medicaid level (determined via the Title V staff) - constitutes the benefits of the program.

The state is addressing any potential "cliff effect" by a combination strategy of an annual enrollment fee and a one-year buy-in at full premium costs for enrollees whose family income increases above 200% FPL to 225% FPL. This is designed to serve as a “weaning” or transition period to private health care coverage.

During application processing, the existing Title XIX Eligibility Information System (EIS) is queried to ascertain if the child has Title XIX coverage or other insurance coverage. The application is simultaneously assessed for Title XIX eligibility and Title XXI eligibility and the child is enrolled in whichever program he or she is eligible to be enrolled.

Through outreach, the Department of Health and Human Services collaborates with and coordinates appropriate communications resources and activities between and among Title XXI and such ongoing programs and efforts as WIC, Maternal and Child Health Block Grant,

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

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Approval Date: 11 Children's Special Health Services, Smart Start and Head Start. NCDHHS also engages the participation of the private sector in providing no-cost or low-cost avenues for publicizing the Title XXI program in local communities statewide. These have included working with providers across the state to outreach to their patients who need the program and to solicit their input on the effective operation of the program.

The Robert Wood Johnson “Covering Kids and Families” funds, managed under the auspices of the NC Pediatric Society Foundation, is stressing reenrollment efforts, preventive health efforts and innovative uses of technology to prevent the inadvertent loss of home/mailing addresses of member children.

The Provider Task Force of NC Health Choice continually assesses both how the provider community (defined as primary care practitioners as well as representatives of vision, dental, hearing and mental health specialties) can assist in assuring both enrollment and reenrollment by families, and how to entice more providers into providing care to NC Health Choice patients. These efforts have included, but are not limited to: peer-to-peer visits among Health Choice and non Health Choice dentists, conversations among providers at specialty meetings, etc. Meetings with the office managers association have successfully ensured that “We take NC Health Choice” signs are posted in the doctor’s office, and that office workers check enrollment dates on cards so that families can be reminded to reenroll. The Provider Task Force has also been successful in addressing certain gaps in service. One notable effort included the addition of dental sealants; fluoride varnish for children and pulpotomies and steel crowns as covered services.

The Governor’s Commission on Children with Special Health Care Needs is charged with assessing and recommending improvements in the special needs services to all children in the state, with a particular attention being paid to NC Health Choice. The commission has examined the relationships between schools and health providers in the area of children with behavioral health care needs. They were responsible for recommending changes in residential care criteria and for assuring that special needs children were exempted from an existing period of uninsurance. The success of this amendment led to the removal of a period of uninsurance as an eligibility requirement for all NCHC children.

Other cooperative efforts have included the inclusion of NC Health Choice advertisements on the inside cover of WIC folders, and NC Health

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

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Approval Date: 12 Choice’s role in a pilot program to enhance voluntary use of “health homes” for children. These efforts have contributed to increased levels of cooperation and ownership in the program. More importantly, they have led to a provider/community network that is dedicated to the overall improvement and long-term existence of the program.

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

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Approval Date: 13 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

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

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

The State of North Carolina provides health insurance benefits through a plan managed by the NCDHHS with health benefits provided through the Teachers and State Employees Comprehensive Major Medical Plan, from hereon referred to as the State Employees Health Plan - a program offering fee-for-service to any willing provider for indemnity health insurance. Benefits and claims processing are administered by the State Employees Health Plan, and eligibility is determined by county departments of social service (DSS). Upon determination of eligibility (and receipt of any applicable enrollment fee), the county Medicaid eligibility specialist enters the member’s information into the statewide Eligibility Information System (EIS). Through the Division of Medical Assistance (DMA), EIS then electronically forwards Title XXI eligibility information to the State Employees Health Plan and sends notification of eligibility to families. The State Employees Health Plan then sends families information about the Plan of Benefits and processes claims.

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

The same utilization controls used in the State Employees Health Plan are also used in the Title XXI program. The State Employees Health Plan is established and operated under North Carolina General Statute 135-37 through 135-41.3. Medical necessity, pre-certification, prior approval, fraud detection, auditing and extensive reporting detailing utilization are provided for by the State Employees Health Plan and through its contract with its claims processing contractor, Blue Cross/ Blue Shield of North Carolina.

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

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Approval Date: 14 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

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

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

4.1.1.

Geographic area served by the Plan: entire state of North Carolina 4.1.2.

Age: Six to the 19th birthday 4.1.3.

Income • At or below 200% of the federal poverty level (FPL) • Methodologies for determining family income will be the same as for Title XIX • Allow deduction for child care and standard work expense consistent with Title XIX poverty level group. • A family must present pay stubs of all working household members for one month prior to enrollment. A small business owner must present business income proofs acceptable to the Medicaid program • Family size is determined by counting all children in the home in the needs unit of the children applying for SCHIP, including those children receiving Medicaid. 4.1.4. Resources (including any standards relating to spend downs and disposition of resources 4.1.5.

Residency (so long as residency requirement is not based on length of time in state): Resident of North Carolina 4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7.

Access to or coverage under other health coverage: Uninsured means the applicant is, and was not covered under, any private or employer-sponsored creditable health insurance plan on the date of enrollment into the program, and is ineligible for Medicaid, Medicare or other federal government sponsored insurance. The child must be in a family that meets the following family income requirements: at or below 200% of the federal poverty level and above current NC Title XIX levels (6-18—100%). This will be

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

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Approval Date: 15 determined by the county Social Services case worker after all other eligibility criteria have been established. Enrollment in the plan will begin on the first day of the month following a verified date for end of coverage. Cases that qualify due to dropping private insurance will be electronically coded so the state may determine if the crowd out rate is impacted.

4.1.8

Duration of eligibility: 12 months 4.1.9.

Other standards (identify and describe):

• Eligible under federal law • Ineligible for coverage under Title XIX • Not an inmate in a public institution • If income over 150% FPL, have paid the enrollment fee (with the exception for members of federally recognized Native American tribes.) • Each recipient child shall provide a social security number. A non-recipient parent is not required to submit his own social security number in order for his children to be considered.

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

4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.

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

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

Enrollment process:

Families may apply using mail-in applications that can be found at local health departments, and county DSS offices, and on special displays at a variety of locations including but not limited to grocery stores, pharmacies, and discount stores. Applications can also be found at the human resources (personnel) offices of major employers, through all federally funded programs, targeted outreach to public schools and day

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

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Approval Date: 16 care centers (by calling the toll-free hotline published extensively by Title V and DMA), and in person at specially designated outstations. In addition, families may obtain applications at specified medical providers, including Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC), migrant health centers, and Indian health centers. Certain State agencies with frequent public contact such as drivers license and vehicle tag sites also have mail-in application forms available.

Enrollment form:

A self-completed, simplified mail-in application form is used for families with children for both Title XIX and Title XXI. Forms are available in Spanish. These forms were developed through focus groups and tested for ease of readability. Assistance in filling out the forms is available through county DSS offices and at specially designated outstations (see above). Information and a mail-in application form are available and posted on the NC Health Choice site on the internet (http://www.dhhs.state.nc.us/dma/cpcont.htm).

Enrollment fee:

Before a child can be enrolled, a family enrollment fee of $50 for one child or $100 for two or more children shall be paid to the County DSS for those families whose income falls between 150% and 200% of the federal poverty level. Upon presentation of proof of membership in a federally recognized Native American tribe, this requirement shall be waived. These funds are kept by the county to help offset its administrative costs.

Eligibility Determination:

• NC Health Choice provides 12 months continuous eligibility without regard to changes in income. • County DSS determines eligibility for both Title XIX and Title XXI. • County DSS evaluates whether there is Title XIX eligibility, obtain income verifications, and request any additional information if necessary. If income is within Title XIX limits, the child will be enrolled in Medicaid. If over the Medicaid income limit but within 200% of FPL, the child will be enrolled in Health Choice. • Applications are processed within the standard for Title XIX applications (i.e. 45 days from the date of application.) • Counties will collect an enrollment fee when family income is at or above 150% of the federal poverty level unless the family when

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

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Approval Date: 17 declaring race has presented evidence (such as a Tribal Membership Card) that they are members of a federally recognized Native American tribe. If this has occurred, no enrollment fee is owed. • Because North Carolina State Employee dependents receive no subsidy from government sources and parents must pay full premium costs, children of state employees and teachers have been determined to be eligible for coverage under Title XXI.

Enrollment Method:

• County DSS enters enrollment information into statewide Eligibility Information System (EIS) • The EIS sends eligibility updates nightly to the State Employees Health Plan. • EIS generates a notice of denial or approval for benefits for the applicant. • The State Employees Health Plan sends out health identification cards, benefits booklets (in English and Spanish), and other related program information.

Continuing Enrollment:

• NC Health Choice provides 12 months continuous eligibility without regard to changes in income. • Local agencies receive a "kit" of materials to assist in publicizing ongoing enrollment efforts. • During the eleventh month following enrollment, individuals are sent: (1) a post card asking them to expect a reenrollment form, and (2) a copy of the mail-in application form with a cover letter reminding them that it is time to apply to continue enrollment. • Re-enrollment requirements are the same as initial enrollment. For continued enrollment, the family is sent a form with address information completed on it. Forms may be self-completed/edited, signed and mailed into county DSS. • The local agency has administrative flexibility to use mail-in requests for information, telephone follow-up, and face-to-face interviews.

The experience of the typical enrollee will be as follows:

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

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The family, upon hearing about this opportunity and then receiving written material at their child's day care (or other source), fills out the application form and mails it to the county DSS office. The local DSS worker assesses the form and makes one of three possible determinations:

1. The child is eligible for Title XIX. This information is data entered and the child is enrolled in Medicaid.

2. The child is eligible for Title XXI. This information is data entered and sent to the Division of Medical Assistance, whereupon one of two things happens: (a) the child is enrolled in the Title XXI program upon receipt of an enrollment fee for families above 150% of poverty ($50 enrollment fee for one child and $100 fee for two or more children paid to the county Department of Social Services) and their information is forwarded to the State Employees Health Plan for inclusion in the program, or (b) it is determined that the funds have been depleted and the child is denied and placed on a waiting list.

If the child is found eligible for either Title XIX or XXI and is enrolled, the family will receive by mail a card for the child and written instructions. In the case of Title XXI participants, the cover letter and card will be generated by State Employees Health Plan to welcome them to the program. The letter will inform the parent(s) how to access their children's providers and will include information on copays, out of pocket limits, etc. For children enrolled in the Title XXI program, during the eleventh month of eligibility the family will automatically receive a mail-in application form with a cover letter reminding the family that it is time for plan renewal.

3. The child is ineligible for both Title XIX and Title XXI either due to income and/or insurance coverage. In the event of an enrollment freeze an enrolled child whose family submits a valid application for reenrollment prior to the end of the ten-day grace period will be reenrolled in the program.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

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

Effective Date:

Approval Date: 19 Check here if this section does not apply to your state.

Effective January 1, 2006, the enrollment growth of Title XXI, Health Choice, is limited to three percent every six months. In the event that enrollments in the program exceed the three percent cap or the available budget, The Secretary may halt new enrollments until such time as enrollment levels are administratively deemed to be budgeted within the legislated parameters. Notifications will be provided to the US DHHS CMS 45 days in advance of the implementation of any enrollment cap. Public notification will be announced to the current enrollees by letter 30 days prior to the imposition of an enrollment cap and to the news media no later than 20 days before a new enrollment cap is to be implemented. The purpose of the plan is to limit enrollment in a manner that does not impose an extra burden on families to file multiple applications and it allows children to enroll as slots become available rather than waiting for a pre-established date. The initial closure will last a minimum of two months to allow the first full set of re-enrollments to have grace period and to build a safety buffer of open slots.

Enrollments shall be permitted as follows:

Families will continue to file applications and counties will determine eligibility as usual. If a child is determined eligible for Medicaid, then the application is approved and the child is issued benefits. If the child is determined ineligible for any program, the application is denied. If the child qualifies for NC Health Choice, the application will be denied and the family will be notified that the child qualifies for the program but that no funds are available for the program. The state’s Eligibility Information System (EIS) will establish a computerized waiting list and add the child to the waiting list. Information about the child will not be transmitted to the claims processing agent until such time as the program enrollment is reopened.

Should the family be an existing NCHC family and re-enroll during the 10-day grace period, the children will continue to have coverage.

Reactivation of applications from the waiting list.

When the NCDMA determines that it is financially possible to allow for new enrollees, it will notify the Division of Information Resources Management (DIRM) of the number of slots that can be filled. US DHHS CMS will be notified on the same day that DIRM receives its notification.

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

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Approval Date: 20

At the point of application, a registration number will be filed so that the applications can be sequenced chronologically according to the date originally registered in EIS. The applications will be reactivated on a first-come, first-serve basis according to this chronological order. When a child’s application is reactivated, he or she is removed from the waiting list. The family is mailed notification that its application has been re-opened. The notification letter asks that the family confirm its address and uninsurance status and to return it to the state. This permits the state to act on the family’s behalf and reactivate the application. A maximum of 45 days processing time will be allowed for the application to be considered and for the family to provide any needed information.

If the family does not return the reactivation notice the county checks agency records to see if an address change has occurred and will mail a second notice. The county DSS acts on the returned notice to complete the application. The DSS notifies the family if there is any enrollment fee due and the family is asked to pay it. The family is officially notified of the outcome of the reopened application and the child(ren)’s record is transmitted to the claims processing agent. Benefits begin the month the application was "re-activated" and will continue for 12 consecutive months (e.g. the month of ‘re-activations’ is month 1 of the 12 months).

Should a family not reply within 45 days, the "re-activated" application is denied: the number of slots represented by the children in the family become available. The children do not return to the waiting list. The family can reapply at any time.

In the event that the budget shortfall or growth cap is eliminated, the backlogged wait-listed children must be enrolled in the program before the process returns to one with no waiting list.

If a case on the waiting list is re-activated within 3 months, then families will reaffirm their insurance status. The State will use the income that was verified when applicant first applied to determine eligibility when re- activated. If a case is on the waiting list longer than 3 months, then the insurance and income will be reaffirmed at re-activation.

All families will receive a reactivation letter that will ask them to respond to the county DSS within 10 calendar days. If the initial letter is returned to the county DSS because it couldn’t be delivered, the county will follow established procedures to determine a current address. Once a current

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

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Approval Date: 21 address is found, the letter will be mailed to the family. The family will be given 10 calendar days to respond. The 45-day processing period will begin the day the case is reactivated. We will be electronically opening an application. The two, ten day periods will fall within that 45 days.

Children will be taken off the waiting list on a first come-first serve basis, regardless of medical condition or income level.

CMS will be notified before any freeze is put into place or any waiting list is initiated. There will also be public notice to the families and through the media before such time as a waiting list is to be imposed.

Regarding children who are required to pay enrollment fees in order to reenroll, the enrollment fee is part of the enrollment process. Failure to pay the enrollment fee is tantamount to not completing the enrollment process. Should the enrollment fee not be paid for reenrollment, the child would be denied reenrollment and would have to go onto the waiting list. Children who have applied and found eligible for the program and are placed on the waiting list for any reason, do not have to pay the enrollment fee until they are permitted to go off the waiting list and enroll in the program. At that point in time, if their family income so dictates, they must pay the enrollment fee to enroll in the program.

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

Income limits for eligibility for Title XXI are higher than those for Title XIX for children ages six through 18. Screening determines eligibility under the appropriate program. During the application process, the existing Title XIX Eligibility Information System (EIS) are queried to ascertain if the child has Medicaid coverage. The application is first processed for Title XIX eligibility; Title XXI will be pursued only if the child is ineligible for regular Title XIX services, and only for children without existing health care coverage. Income will be assessed at application and at annual redetermination of eligibility. All eligibility in Medicaid and Title XXI is continuous for 12 months without regard to income.

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

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Approval Date: 22 Computerized edits in the Eligibility Information System will prevent enrollment in Title XXI if income is within Title XIX threshold levels. Because state employees and teachers in North Carolina pay full price for their health insurance with no governmental subsidy of any kind, employees of the State of North Carolina are eligible for the program.

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

The State uses the same mechanisms and entities in the eligibility determination process for Title XIX and Title XXI. Eligible children are enrolled in the appropriate program as determined by eligibility criteria. One worker processes an application (same application for both Title XIX and XXI). After other criteria are met, the worker assesses family income and determines if the child is eligible for Title XIX or Title XXI or ineligible for either.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

The State uses the same mechanisms and entities in the eligibility determination process for Title XIX and Title XXI. Eligible children are enrolled in the appropriate program as determined by eligibility criteria. One worker processes an application (same application for both Title XIX and XXI). After other criteria are met, the worker assesses family income and determines if the child is eligible for Title XIX, Title XXI or ineligible for either. If a Medicaid eligible family (or children) reports increased income that makes them ineligible for Medicaid, the children are automatically assessed for SCHIP eligibility.

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

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

The applicant must not be covered under any private

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

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Approval Date: 23 or employer-sponsored, creditable health insurance plan on the date of enrollment into the program, and is ineligible for Medicaid, Medicare or other federal government sponsored insurance. Cases that qualify due to dropping private insurance will be electronically coded so the state may determine if the “crowd out” rate is impacted. Each case is processed through a system to match the family to the primary insurance providers in North Carolina. It is the same system used for Medicaid. In addition, the claims processor runs periodic screens to double check the child’s insurance coverage. If creditable insurance coverage is found, the claim is denied and the case is referred to the Division of Medical Assistance, Program Integrity Fraud Unit.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. 4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution. 4.4.4.4. If the state provides coverage under a premium assistance program, describe:

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

The minimum employer contribution.

The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

All children in the state who are eligible for assistance will be targeted through outreach efforts specifically outlined in Section 5. Organizations that provide outreach to the Native American population will also be targeted. Representation from the Commission on Indian Affairs and the Eastern Band of the Cherokee serve on the Outreach Committee and assisted in the

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

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Approval Date: 24 crafting of both the overall Outreach Strategy and the specific strategy to best reach the State’s Native American community. Native Americans who are members of a federally recognized tribe do not have any out of pocket cost under the program. NC Health Choice has worked closely with the Eastern Band of the Cherokee to assure that all families with potentially eligible children have been reached and told of this program and the benefits it offers to the child and the tribe.

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

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Approval Date: 25 Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

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

North Carolina employs a simple, seamless marketing approach for both the Title XIX and XXI Programs. Marketing approaches use social marketing research and consider the needs of diverse populations (e.g., bilingual, TTY, etc.) The Division of Public Health has added a position focusing specifically on outreach for Medicaid and Health Choice for minority populations including African American, Native American, Hispanic/Latino and Hmong. Outreach/promotion and marketing are coordinated at the State level through existing public/private partnerships. The Outreach Coalition meets jointly with the RWJ Covering Kids and Families to each strengthen the efforts of the other. The Outreach Coalition is co-chaired by the North Carolina Pediatric Society Foundation and alternates between the Division of Medical Assistance and the Division of Public Health. The Coalition includes the Office of Rural Health and Resource Development, the Commission on Indian Affairs, the Departments of Public Instruction, the NC Partnership for Children, the NC Covenant for Children and the NC Health Access Coalition among others. The state works collaboratively with First Step outreach efforts (a State effort to reduce infant mortality), has a hotline to provide information, referral and advocacy services to the parents of children who may be eligible for Title XIX or XXI Programs. Has a separate hotline to deal specifically with families of children with Special Health Care needs. There are activities at the community and state level to engage organizations, health care providers and consumers in outreach and enrollment efforts. In fact, a Providers Task Force comprised of health care providers (Major Medical Centers, the NC Hospital Association, the Pediatric Society, the NC Academy of Family Physicians, the NC Dental Society, the NC Opticians Society, the NC Association of Independent Pharmacists and others) has supplemented the state’s outreach effort and engaged the providers of the state in outreach activity as well as participation in the program. The state also works with counties to assist them in locally-based outreach/promotion & marketing, enrollment and utilization, and tracking activities. The State marketing efforts assist local designees with enrollment drive activities.

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

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Approval Date: 26 Eligibility Determination/Enrollment

The outreach strategy has two goals. The first goal is to increase general awareness of the increased access the program offers to families in North Carolina; second, to assist in educating families about how to best use the health care system to improve the wellbeing of their children.

The overall outreach strategy provides a number of program benefits:

(1) to assure that children who are eligible for Title XIX are enrolled in Title XIX; (2) to prevent children from being inadvertently enrolled in two programs; (3) to provide one consistent source of enrollment data, and (4) to avoid a substantive investment to create a new computerized information system for Title XXI.

The State has implemented Federal options to simplify the Title XIX and XXI enrollment process including annual re-determination, a simplified application, decentralized enrollment through out-stationed staff (enrollment "drives") and the development of a mail-in application. In addition, the State explored and engaged as many others as possible in the outreach and enrollment process (e.g. public/private providers, schools, Smart Start, day care, work sites, etc.) Title XXI and Title XIX now have continuous eligibility for 12 months without regard to changes in income.

Implementation

In each county outreach is conducted through collaborative implementation efforts between the local Departments of Health and Social Services with guidance from the State Outreach Coalition.

General public awareness campaigns have been conducted through the NC Healthy Start Foundation (a 501 C-3 organization) with statewide media campaigns conducted through the Public Information Office of NCDHHS. The name of the program was selected through focus groups conducted statewide. County-based publicity kits were developed by the National Covering Kids Campaign and by the Healthy Start Foundation.

Local Department of Social Services employees identify potentially eligible families and facilitate the completion of applications. These efforts include working with child care providers and public schools to

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

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Approval Date: 27 solicit their help in identifying eligible families and assisting them with the application process. In addition, the assistance of the NC Council of Churches has been sought to encourage all places of worship to inform their congregations of the importance of the availability of children's health insurance, Titles XIX and XXI and to assist in the application process. The assistance of the NC Pediatric Society and the NC Academy of Family Physicians was enlisted to provide their patients with information on Titles XIX/XXI. Providers have also been urged to remind patients to reenroll when their 12-month eligibility period was about to expire.

Using a simplified mail-in application form, applicants first are screened for Title XIX eligibility, then for Title XXI. If they are found to be ineligible for both programs, applicants are provided with information on Title V clinics for preventive health services at the local health department. They are encouraged to consider purchasing health insurance for their children. The process was developed in such a way that trips to local social services agencies are not necessary. Mail in applications, out- stationed sites and telephone interviews are used. Because eligibility is one year only, renewal applications are mailed at 11 months with a cover letter explaining where to turn for assistance if help is needed in completing the renewal application.

Targeted Population Outreach

The Division of Public Health has added a position focusing specifically on outreach for Medicaid and Health Choice for minority populations including African American, Native American, Hispanic/Latino and Hmong. North Carolina's minority populations have been successfully targeted through a combined approach using minority media, religious organizations, social and cultural organizations. The broad outlines for minority outreach efforts, developed by representatives of the respective racial or ethnic groups are as follows:

The African American population is targeted through:

• 11 newspapers in the state identified by the NC Black Publishers Association as those with an editorial focus targeting black readers. • Urban, Gospel and Jazz radio stations as listed through Arbitron Media Research as African American • Predominantly African American religious organizations through such projects as Black Churches United for Better

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

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Approval Date: 28 Health. • Such social and service organizations as the NAACP and service sororities and fraternities

Native Americans in North Carolina are targeted through:

• The North Carolina Commission on Indian Affairs • Pow-wows held statewide • Tribal newsletters and two newspapers which target Native American readers. • Tribal organizations • Native American Youth and Cultural Groups • Community Action Agencies • Rural and Migrant Health Centers

Hispanic Communities are reached through:

• Four Hispanic newspapers • Spanish language television and radio stations • Community Action Agencies • Rural and Migrant Health Centers • Community grocery stores

Homeless families in North Carolina are targeted through:

• Rescue Missions • Church Shelters • Health Departments • Local Social Services Departments • Community Action Agencies • Rural and Migrant Health Centers

Information and a (U.S.) mail-in application form are posted on the Internet.

A Medical Home

As NC Health Choice population began to exhaust the dollars available through state funds, it became clear that it was time to assist NC Health Choice members’ parents to better understand how to best use the health care system and how to keep their children healthy. With this, targeted efforts to promote wellness and disease management strategies were implemented. A claims

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

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Approval Date: 29 analysis revealed that the leading causes of emergency department visits were for otitis media, fever and upper respiratory infections. Materials have been developed in both English and Spanish helping parents to know what to do, when to see their child’s doctor and when to go to the emergency room. Additional materials have been developed to encourage families to choose a provider to become their child’s medical home so that they will always have someone who knows their child to turn to for help as well information on how to prepare for a doctor’s visit so that it will work for the child.

Efforts have also been undertaken to identify children with asthma and to assure that they are receiving all the help they need to prevent emergency episodes. One of the major foci of the program right now is medical management: identification of frequent or high cost episodes and outreaching health information to those families.

5.2. Coordination of the administration of this program with other public and private health insurance programs: (Section 2102(c)(2))

The strategies for outreach/promotion and marketing, and eligibility determination/enrollment are identical for both the Title XIX and XXI programs as outlined in 5.1. The Division of Medical Assistance administers the program in concert with the local Departments of Social Services for determination of eligibility. Children are determined eligible or ineligible for Title XIX using the same application form as for Title XXI.

Children who are not eligible for Title XIX are evaluated for Title XXI eligibility and automatically enrolled if income criteria are met. Outstationed eligibility staff, including those placed at Federally Qualified Health Centers and Disproportionate Share Hospitals, accepts applications for both Title XIX and XXI programs through a common process.

Applications are made available on self-service displays in easy access locations.

An enrollee in the Program who loses eligibility due to an increase in family income above 200% FPL and up to and including 225% FPL may purchase at full premium cost, continued coverage under the Program for a period not to exceed one year beginning on the date the enrollee becomes ineligible under the income requirements for the Program. The same benefits, co-payments, and other conditions of enrollment shall

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

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Approval Date: 30 apply to extended coverage.

No State or federal funds are used to cover, subsidize or otherwise offset the cost of this extended coverage.

The Department coordinates efforts with the State Health Plan to assure that children with “special needs” receive the same level of services that are available under Title XIX in North Carolina, including case management services to enhance outcomes and control costs. A special fund, comprised of Title XXI federal funds and state matching funds will be established to reimburse the services that are above and beyond those covered by the State Health Plan. This component will be administered by the State Title V Children’s Special Health Services Program in the Department. “Children with Special Needs” are those who have been diagnosed as having one or more of the following conditions which in the opinion of the diagnosing physician (1) is likely to continue indefinitely, (2) interferes with daily routine, and (3) requires extensive medical intervention and extensive family management:

a. Birth defect, including genetic, congenital or acquired disorders; b. Developmental disabilities; or c. Chronic and complex illness

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

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

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

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420) 6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment (Section

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

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Approval Date: 31 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2.

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

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

6.1.4.

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

6.1.4.1. Coverage the same as Medicaid State plan 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage

Base plan is benchmarked in the State Employees Health Plan plus dental, vision and hearing coverage and special needs coverage to the Medicaid level. 6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit-by-benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. Other (Describe)

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

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Approval Date: 32 6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

6.2.1.

Inpatient services (Section 2110(a)(1))

Room and board (semi-private accommodations, unless the hospital has only private rooms); medically necessary supplies; medication; laboratory tests; radiological services; operating/recovery rooms; and hospital staff. Hospital admissions must be pre-certified. The State Health Plan requires a second surgical opinion for coronary artery bypass; hysterectomy; knee surgery; revision of nasal structure; unless the procedure is performed on an emergency basis. 6.2.2.

Outpatient services (Section 2110(a)(2))

The State Employees Health Plan provides benefits for covered diagnostic services, therapies, laboratory, radiology, and surgeries provided in a hospital outpatient setting or in an ambulatory surgical facility; preadmission diagnostic tests before hospital admission within 14 days of a scheduled hospital admission.

6.2.3.

Physician services (Section 2110(a)(3))

Eligible medical providers are Doctor of Medicine; Doctor of Osteopathy; Doctor of Podiatry; Doctor of Chiropractic; office visits for preventive services such as unlimited well- baby visits up to one year of age; 1 visit per year between 2 and 7; once every three years between seven and 19 years of age. Immunizations are covered.

6.2.4.

Surgical services (Section 2110(a)(4))

Standard surgical procedures; related services; surgeon's fees, including preoperative and some post-operative visits; anesthesia. Assistant surgeons are covered when medical judgment requires surgical assistance and no hospital- employed physician in training is available. When two or more surgical procedures are covered at the same time if there are separate incisions, the surgeon will be paid at the rate of the higher usual and customary charge and 50% of

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

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Approval Date: 33 the charge of the second procedure. If the same incision is used, the surgeon will be paid for the one surgical procedure that has the higher UCR allowance. Prior approvals are needed for abdominoplasty, blepharoplasty, cochlear implants, excision of gynecomastia, fimbrioplasty, gastric surgery for morbid obesity, hermaphroditism, keloid excision, nasal structure revision, oral surgery (developmental and congenital orthognathic surgeries, necessitated as a direct result of medical treatment), penile prosthesis, reduction mammoplasty, subcutaneous injection, suction lipectomy, temporomandibular joint (TMJ) dysfunction appliance therapy (limited to injury), transplants, tubotubal anastomsis.

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

The State Employees Health Plan provides benefits for covered diagnostic services, therapies, laboratory, radiology, and surgeries provided in a hospital outpatient setting or in an ambulatory surgical facility; 1 visit per year between 2 and 7; once every three years between seven and 19 years of age. Immunizations are covered.

6.2.6.

Prescription drugs (Section 2110(a)(6))

6.2.7.

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

6.2.8.

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

6.2.9.

Pre-natal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

Prenatal care and childbirth are not covered. Counseling and advice about contraception and prescription drugs for contraception are covered.

6.2.10.

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

Pre-certification must be obtained from the Mental Health

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

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Approval Date: 34 Case Manager (in order to be eligible, patient must be confined to a licensed mental health bed and treated by an eligible mental health provider) for the following: residential treatment in a psychiatric setting, urgent admissions, chemical dependency, psychological testing (except when included in the hospital's or treatment program's daily charge, hypnotherapy, sodium amytal interviews, electroconvulsive treatment; stress, relaxation and occupational therapies (except when included in the hospital's or treatment program's daily charge); psychosurgery.

6.2.11.

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

More than 26 outpatient visits per plan year (combined with outpatient substance abuse visits) require precertification from the Mental Health Case Manager (patient responsible for keeping track of the number of visits); psychological testing over and above that performed during the 26 visits will also require pre-certification from the Mental Health Case Manager.

6.2.12.

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

Must be standard equipment that is normally used in an institutional setting, able to withstand repeated use, primarily and customarily used to serve a medical purpose, generally not useful in the absence of an illness or injury, appropriate for use in the home (such as a standard hospital bed, standard wheelchair, nebulizer, etc.) and not used for the convenience of the caregiver, reasonable and medically necessary for the treatment of a specific illness or injury.

VISION: Scheduled routine eye examinations once every 12 months, eyeglass lenses or contact lenses once every 12 months, routine replacement of eyeglass frames once every

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

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Approval Date: 35 24 months, and optical supplies and solutions when needed. Optical services, supplies and solutions must be obtained from licensed or certified opthamologists, optometrists, or optical dispensing laboratories. Eyeglass lenses are limited to single vision, bifocal, trifocal, or other complex lenses necessary for an enrollee's visual welfare. Coverage for oversized lenses, designer frames, photosensitive lenses, tinted contact lenses, blended lenses, progressive multifocal lenses, coated lenses, and laminated lenses is limited to the coverage of single vision, bifocal, trifocal or other complex lenses. Eyeglass frames are limited to those made of zylonite, metal or a combination of zylonite and metal. All visual aids require prior approval of the State Health Plan. Upon prior approval by the State Health Plan refractions may be covered more often than once every 12 months. HEARING: Auditory diagnostic testing services and hearing aids and accessories when provided by a licensed or certified audiologist, otolaryngologist, or other hearing aid specialist approved by the State Health Plan. Prior approval of the State Health Plan is required for hearing aids, accessories, earmolds, repairs, loaners, and rental aids.

6.2.13.

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

6.2.14.

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

The State Employees Health Plan limits home and community-based services to patients who are homebound, need for therapy that can only be performed by licensed health care professionals, physician -certified that the patient would otherwise be confined to a hospital or skilled nursing facility without home care services, must have rehabilitation potential. Require prior approval and include private nursing duty, home care aides (under the direct supervision of a registered nurse and employed by a licensed home care agency), skilled nursing visits, hospice care, therapy (speech, physical and occupational, and home intravenous (IV) therapy. Intensive in-home behavioral health services are covered under the Core Benefit portion of the plan as a specialized intensive outpatient program. These services include crisis management, parent

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

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Approval Date: 36 reeducation or family systems therapy. Not covered are care provided by a family member, care provided by a non-skilled or unlicensed care giver, such as a sitter, when the patient's condition no longer requires a skilled level of care, when the maximum rehabilitation potential has been met.

6.2.15.

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

6.2.16.

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

Abortion is not covered.

6.2.17.

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

Oral examinations, teeth cleaning, and scaling twice during a 12-month period, full mouth X rays once every 60 months, supplemental bitewing X rays showing the back of the teeth once during a 12-month period, fluoride applications twice during a 12-month period, sealants, simple extractions, therapeutic pulpotomies, prefabricated stainless steel crowns, and routine fillings of amalgam or other tooth colored filling material to restore diseased teeth.

6.2.18.

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

Pre-certification must be obtained from the Mental Health Case Manager (in order to be eligible, patient must be confined to a licensed substance abuse bed and treated by an eligible substance abuse provider) for the following: residential treatment in a psychiatric setting, urgent admissions, chemical dependency, psychological testing (except when included in the hospital's or treatment program's daily charge); hypnotherapy; sodium amytal interviews; electroconvulsive treatment; psychosurgery. Detoxification may be obtained on a licensed medical unit, psychiatric unit, or substance abuse unit if pre-certified by the mental health case manager.

6.2.19.

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

More than 26 outpatient visits per plan year (combined with

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Approval Date: 37 the outpatient mental health visits) require pre-certification from the Mental Health Case Manager (patient responsible for keeping track of the number of visits); psychological testing over and above that performed during the 26 visits will also require certification from the Mental Health Case Manager.

6.2.20.

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

6.2.21.

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

6.2.22.

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

6.2.23.

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

6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24))

The Department will coordinate efforts with the State Health Plan to assure that "children with ‘special needs’" receive the same level of services that are available under Title XIX in North Carolina. Service requests for children with special needs are reviewed by one or more of the following: Division of Public Health specialty clinicians, contracted vendor for mental/behavioral health (including behavioral health group homes) and/or nurses/physicians at claims processing contractor. Funds and service utilization for CSHCN, above the core services are regularly tracked and analyzed to improve proactive program and budget planning. The State Title V program for Children with Special Health Care Needs has lead responsibility for coordinating services and benefits for children who are medically high cost and for children meeting the following definition:

“Children with Special Needs" are those who have been diagnosed as having one or more of the following conditions which in the opinion of the diagnosing physician (1) is likely to continue indefinitely, (2) interferes with daily routine, and (3) requires extensive medical intervention and extensive family management:

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a. Birth defect, including genetic, congenital or acquire disorders; b. Developmental disabilities; or c. Chronic and complex illness.

6.2.25.

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

6.2.26.

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

Ambulance transportation is covered including air ambulance under certain emergency situations

6.2.27.

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

6.2.28.

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

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

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

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

6.4 Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

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

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

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

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Approval Date: 40 6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2.

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

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

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

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

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Approval Date: 41 Section 7. Quality and Appropriateness of Care

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

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

The Department will perform satisfaction surveys. A random sample of all participating families will be asked to complete a survey periodically. Questions on the survey will be determined by input received from families, providers, and experts/researchers in the field. Sample measures are:

• Proportion of parents that rate the care provided to the child is poor, appropriate, good, or excellent • Proportion of parents reporting that they are satisfied with their role in making decisions about their child's care • Proportion of parents reporting satisfaction with the availability and choice of primary and specialty providers. • Proportion of parents reporting satisfaction with the amount of time providers spend with the child • Proportion of parents who filed formal complaints or grievances. • Average waiting time for appointments for preventive; primary, or specialty care. • Travel time and distance to receive preventive, primary and specialty care.

The use of prevention services will be evaluated through the following measures.

Well-child screening rate, by age (AAP standards)

• ages 6-11 • ages 12-18

The rate of use of acute care services will be measured by the following measures:

• Number and rate of ambulatory visits per 1000 member months, by age

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Approval Date: 42 • Number and rate of emergency room visits per 1000 member months • Number and rate of hospital stays per 1000 member months, by age • Average length of hospital stay

The adequacy of services for special needs children will be measured with advice from the NC Commission on Children with Special Health Care Needs. Attention will be focused on children with high cost and/or high incidence conditions such as:

• Asthma • Diabetes • Emotional Behavioral Conditions

Measures for these children may include:

• Proportion of children who have hospital stays, and length of stay • Percent of children requesting/receiving durable medical equipment • Types and number of mental health/behavioral health services received by age of child • Information from periodic surveys where questions target CSHCN • Use of emergency room by CSHCN

Notable gaps in service act as trigger points for consultation with the Commission for Special Health Care Needs to evaluate the service and develop a recommendation to improve care for the consideration by the Secretary of DHHS and the NC General Assembly.

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1.

Quality standards 7.1.2.

Performance measurement -- HEDIS measures will be used 7.1.3.

Information strategies – parent surveys and claims data will be used

7.1.4.

Quality improvement strategies --

The Provider Task Force has agreed to include as part of its mission, acting as the Quality Assurance/Improvement group to review compliance with quality standards as revised. This team represents state agencies, provider groups, insurers and others associated with

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Approval Date: 43 health care delivery.

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

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

Review of paid claims data, in-house focused studies, independent studies by researchers, parent surveys, comparison with state immunization registry.

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

Review of paid claims data. Department of Insurance laws on access with prudent layperson standards on emergency care. Recent studies have shown that the most frequent reasons for emergency room visits are ear infection, fever, and upper respiratory infection. Materials have been developed to assist families in caring for their children with these conditions and to know when the situation warrants an Emergency Room visit and which does not. Other focused studies on asthma have led to dramatic decreases in ER visits for asthma patients.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

NC Health Choice is an any-willing-provider indemnity plan. Therefore, there are no network providers. There is an internal review of every denied claim to assess whether or not it meets Medicaid criteria. If it does, it is paid according to Medicaid criteria. Families and providers may also appeal any denial of service. DMA, DPH and the State Health Plan periodically conduct focused studies on high cost or high incidence conditions and develop strategic preventive or early intervention protocols. Should a problem exist, an education campaign targeted to providers is conducted.

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

Decisions on prior authorization are made in accordance with the medical needs of the patient 14 days after receipt of a request for services. These are verified through spot checking and provider feedback, parent surveys, and reports from the Claims Processing Contractor.

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Approval Date: 45 Section 8. Cost Sharing and Payment (Section 2103(e))

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

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

8.1.1.

YES 8.1.2.

NO, skip to question 8.8.

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

For all members of federally recognized Native American tribes there is no cost sharing.

For families below 150% of the federal poverty level (FPL), there is cost sharing for prescription drugs only.

For families above 150% FPL, there is an annual enrollment fee of $50 for one child or $100 for two or more children ($100 annual maximum) plus copays.

8.2.1. Premiums:

8.2.2. Deductibles: 8.2.3. Coinsurance or copayments

Copayments:

Families below 150% will pay copayments as follows:

• For prescription drugs: $1 for generic, $1 for brand with no generic available, $3 for generic with a brand available

Families above 150% will pay copayments as follows:

• For prescription drugs: $1 for generic, $1 for brand with no generic available $10 for generic with a brand available; • $5 for each physician visit, dental and optometry visit except for preventive services,

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Approval Date: 46 • $5 for outpatient hospital visits, and • $20 co-payment for unnecessary emergency room use.

Families who have been exempted from cost-sharing as members of federally recognized Native American Tribes will not be subject to copayments and a $0 copayment will be printed on their health insurance card.

8.2.4. Other:

Enrollment fees are required only of those families above 150% of the federal poverty level. These fees, $50 for one child, $100 for two or more children, are used to offset the cost of administration by county Departments of Social Services. These funds are retained by the counties for this use. In a similar fashion, providers keep any copayments paid to them.

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

These charges are prominently posted on the website for the program, in all literature produced for the program, on the application form and on membership cards. Any changes are made through an act of the NC General Assembly which both publicly debates proposed changes and receives media coverage for the changes it makes. Once a change is made, letters are sent to all members in accordance with North Carolina Medicaid’s ten day notification rule. This rule requires that a letter be sent in order for the recipient to know about the change ten days before it goes into effect.

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

8.4.1.

Cost sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.

No cost sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3

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

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Approval Date: 47 8.5. Describe how the state will ensure that the annual aggregate cost sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

The type and amount of co-payment is set at levels that are extremely unlikely to exceed the upper limit. The Division of Medical Assistance, through EIS, will notify the State Employees Health Plan of the limit to the amount of co-pay. The State Employees Health Plan will electronically accumulate the money spent on cost sharing by each individual and notify the family via a letter when the dollar amount is met. The notification can be shown to providers who will then forgive any further co-payment. As a precaution, a report will be generated annually that lists income levels for individuals for whom co-payment amount exceeds 5% of 100% of annual federal poverty guidelines for an individual. This assures that the lowest possible annual income for a Title XXI eligible is the threshold. During federal fiscal years 2002- 03 and 2003-04 period, no families have exceeded the five percent threshold.

In the cases of families who are at or below 150% of federal poverty level, the medication management claims processing system receives computer based case file numbers, when the family reaches the $14 per month limit, the automatic eligibility system will notify pharmacists that no copay is required. In case of error caused by filing delays, a manual review of the data will be run on the fifth of every month and families will be reimbursed should computer notification fail to work.

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

Counties will collect enrollment fee when family income is at or above 150% FPL unless the family when declaring race has presented evidence (such as a Tribal Membership Card) that they are members of a federally recognized Native American tribe. If this has occurred, no enrollment fee is owed. When eligibility is determined and the membership card issued, the figure $0 will be printed on the copayments lines for those families who presented a tribal membership card upon enrollment. In addition, a letter has been sent to the federally recognized Native American Tribal Councils of North Carolina, asking for their assistance in making sure that their tribal members identify themselves at enrollment as members of a federally recognized Native American tribe.

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Approval Date: 48 8.7 Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

The family whose income is above 150% and does not present a tribal identity card and is, therefore, subject to an enrollment fee and that does not pay an enrollment fee is not enrolled until the fee is paid. A family required to pay a copayment that does not pay remains enrolled in the program. An individual provider may at his or her discretion refuse service over non-payment of a copayment. Enrollment fees are the property of the county in which the application is filed. Copayments are the property of the provider. A family can reenroll at any time during the first ten days of the month and have it count as a reenrollment. This becomes a significant benefit during a time of an enrollment freeze when reenrollees are allowed to stay in the program if they reenroll on a timely basis.

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

The State of North Carolina does not disenroll anyone under the current system unless the family actively requests a change of DSS status that makes them Medicaid eligible or if the family notifies the state that they have purchased health insurance. If the State makes changes in the program that would permit disenrollment we would make sure that:

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

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

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

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

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

8.8.1.

No Federal funds will be used toward state matching

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Approval Date: 49 requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.

No cost sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475) 8.8.6.

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

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Approval Date: 50 Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

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

• To reduce the number of uninsured children living in families with incomes below 200% of the federal poverty guidelines. • To encourage utilization of preventive health care services. • To increase child health screenings among enrolled children

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

• Maintain the enrollment in the program within fundable limits • Measured customer satisfaction and reported program utilization will remain at the 90% or better rate. • Analysis of paid claims data at least twice annually to assure well child checkups at appropriate levels

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

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4)) 9.3.1.

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

Using Title XIX’s Medically Indigent Children program measure the increases of children enrolled by parents seeking health insurance only since the inception of the SCHIP program.

9.3.2.

The reduction in the percentage of uninsured children.

Using CPS estimates divide the total numbers of children covered under NC Health Choice and Medicaid by the numbers of uninsured to establish the rate of decrease per year.

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9.3.3.

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

In lieu of a managed care program, NC Health Choice is undertaking an outreach campaign to encourage families to voluntarily select a primary care practitioner. Computer runs of most frequently used providers will help to trigger the initial thrust of the campaign.

9.3.4.

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

Outcomes measures will be assessed by the Provider Task Force and the Division of Public Health to determine progress on identified health problems

9.3.5

HEDIS Measurement Set relevant to children and adolescents younger than 19.(HEDIS-like measures developed for indemnity programs).

NC Health Choice will use the four HEDIS style measures adopted by CMS.

9.3.6.

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

9.3.7.

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

9.3.7.1 Immunizations 9.3.7.2.

Well-child care 9.3.7.3.

Adolescent well visits 9.3.7.4.

Satisfaction with care 9.3.7.5.

Mental health 9.3.7.6.

Dental care 9.3.7.7

Other, please list:

• Asthma measures • Well child screenings

9.3.8.

Performance measures for special targeted populations.

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Approval Date: 52 9.4.

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

9.5.

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

Upon receipt of the Annual Plan Template the NCHC Coordinator sends appropriate template sections to various agencies and requests that information be provided. Usually a meeting is held with all applicable parties to go through an overview of the questions in the report, to explain the importance of compliance with the requests and to set deadlines. In addition a list of quality measures is presented to the Information Technology sections of both the Division of Medical Assistance and Blue Cross Blue Shield to ask that claims analyses be run. Usually a separate meeting with the information technology workers is necessary to clarify exactly which HEDIS data is being requested. The Coordinator gathers all the information and using it, writes the report, sometimes simply cutting and pasting, in other cases substantially rewriting submissions. In many cases, the Coordinator knows some of the information from personal involvement or research and writes it up in total. Through the year, when it is deemed necessary to gather additional data, the Coordinator assesses whether or not the resources exist in state government to run analyses (in which case, requests are submitted to applicable agencies), or if other groups need to be involved. In every case, the Annual Report is submitted for review and edits to all parties and agencies involved in the provision of services for NC Health Choice. Once these edits have been made, and the Report approved by the Division Director, the report is submitted.

9.6.

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

9.7.

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

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Approval Date: 53 9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

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

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

A Task Force was appointed by the Secretary of the North Carolina Department of Health and Human Services to develop recommendations for implementation of the Title XXI Children's Health Plan. Membership of the Task Force included state government officials, local government officials, health care providers from the private sector, recipient advocates, insurance company representatives, Health Maintenance Organization representatives, and various other interested parties. The Task Force worked closely with local advisory groups comprised of representation from county level departments of Social Services, local health departments, area Mental Health agencies (now referred to as Local Management Entities), etc. A copy of the Task Force report can be found at http://www.dhhs.state.nc.us/dma/CHIP/task.htm. In addition, some 10 public meetings were held across the state before the General Assembly met to consider the Title XXI plan. The General Assembly met for six weeks in special session to consider only the Title XXI plan. The session was the subject of intense public scrutiny and input.

The General Assembly established the Governor’s Commission on Children with Special Health Care Needs to assure that the needs of this population are being met. The entire Title XXI program is also subject to monitoring by the Joint Legislative Health Care Oversight Committee.

In addition, an Outreach Advisory Panel was appointed with the ongoing responsibility of assuring public involvement in the program. The Outreach Advisory Panel (as described in Section 5) is designed to maximize public involvement from provider groups, local programs, and an inclusive cadre of racial and ethnic groups. Subsets of each racial and ethnic group have

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Approval Date: 54 been established to design outreach to their respective racial and ethnic groups.

A Providers Task Force also exists to seek advice and counsel of the entire provider community. Members include representatives of the NC Pediatric Society, the NC Hospital Association, the NC Dental Society, the NC Family Practitioners Association, the opticians, hearing specialists, academic medical centers, academic dental centers, etc. The Task Force is consulted on program changes, for assistance with outreach and other advice and counsel.

In 2002-2003, the NC General Assembly requested a status report on NC Health Choice. They requested that the NC Institute of Medicine (IOM) review the program and make recommendations for any changes in the program. Several months of study yielded a list of recommendations which were presented to the General Assembly in their 2003-2004 session. One recommendation that was adopted was to change pharmacy prescription rates to encourage the use of generic medications. Another recommendation from this report that was adopted was to move the 0-5 year olds to Medicaid in order to access EPSDT services and assure continual coverage from birth through age 5.

All changes to the NC Title XXI Plan are required by state law to go through the legislative process and to be subject to the public scrutiny of any law change except for those changes the Secretary of DHHS may make to special needs. Should such a change be planned for children with special health care needs, the change would first be brought before the Governor’s Commission for Special Health Care Needs for that body’s advice and consent. These meeting are public meetings. Before the change could be implemented letters would have to be mailed to family members 30 days in advance of the change and public notice would need to be published in at least one newspaper in the state.

When major change is considered in the program, the Secretary of NC DHHS, the Governor and the NC General Assembly have asked the NC Institute of Medicine (IOM) or other independent body to convene an appropriate mix of members of the legislative, provider groups and advocacy groups to assure that the best alternatives are recommended to the legislative body. All IOM meetings are public meetings.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section

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Effective Date:

Approval Date: 55 2107(c)) (42CFR 457.120(c))

Federally recognized Native American tribes are actively consulted by phone, email, letters and/or visits to discuss questions and procedures regarding outreach, benefits, billing, eligibility and enrollment and cost sharing. In addition, efforts are made to keep non-federally recognized tribes informed and involved through the NC Commission on Indian Affairs, inclusion of representatives from non-federally recognized tribes on statewide outreach groups and through representation of the program by state employees at Pow Wows held by various tribes across the state.

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

All changes to the NC Title XXI Plan (see note on previous page regarding special needs) are required by state law to go through the legislative process and to be subject to the public scrutiny of any law change. Therefore, proposed changes are published in news articles, on television, on radio and in newsletters of various associations and advocacy groups. In addition, when major change is considered in the program, the Secretary of NC DHHS, the Governor and the NC General Assembly have asked the NC Institute of Medicine to call together an appropriate mix of members of the legislature, provider groups and advocacy groups to assure that the best alternatives are recommended to the legislative body. All IOM meetings are public meetings.

In addition, when major change is considered in the program, the Secretary of NC DHHS, the Governor and the NC General Assembly have asked the NC Institute of Medicine to convene an appropriate mix of members of the legislature, provider groups and advocacy groups to assure that the best alterations are recommended to the legislative body. All IOM meetings are public meetings.

For example, in the recent case of a change in cost sharing for prescription drugs, the concept was first raised in fall of 2002 in a meeting of the NC Health Choice Task Force of the NC Institute of Medicine, There were a series of public meetings called at the request of the NC General Assembly and the Secretary of NC Health and Human Services to decide how to best reform NC

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

Effective Date:

Approval Date: 56 Health Choice in light of budget shortfalls. The calling of the NC Institute of Medicine to examine these issues was well publicized in the mass media. The deliberations of the NC IOM Task Force were publicized as were its findings and recommendations. Legislation evolved from these recommendations. Several bills were submitted to the NC General Assembly by their membership. Among the recommendations was a call to attempt to modify behavior among NCHC families by charging nominal amounts for generic drugs and greater amounts for brand drugs. This recommendation passed. Included on the Task Force were representatives of the major advocacy groups for children in the state. Once the legislation passed as part of the budget process of the NC General Assembly 2003 session (July, 2003), letters were sent to members informing them that this change would take place on February 1, 2004. The time was needed to reprogram computers so that we could assure that federally recognized Native Americans would not be charged any out-of-pocket costs. The state worked closely with the Eastern Band of the Cherokee and the Catawba to ensure that these citizens would not be charged out of pocket costs.

9.10. Provide a 1-year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

• Planned use of funds, including: - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment.

• Projected sources of non-Federal plan expenditures, including any requirements for cost sharing by enrollees.

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

Effective Date:

Approval Date: 57

Benefits

Reporting Period FY 2005 Next Fiscal Year 2006

Insurance payments $275,812,039 $291,477,782 Managed Care

Per member/Per month rate @ # of eligibles $168.85 $196.74 Fee for Service

Total Benefit Costs

(Offsetting beneficiary cost sharing payments)

Net Benefit Costs $275,812,039 $291,477,782

Administrative Costs

Personnel $51,695 $69,427 General Administration $6,629,724 $1,424,251 Contractors/Brokers (e.g., enrollment contractors)

Claims Processing

Outreach/Marketing costs $550,935 $936,594 Other

Total Administration Costs $7,232,354 $2,430,272 10% Administrative Cap (net benefit costs ÷ 9) $30,645,782 $32,386,420

Federal Title XXI Share $210,981,291 $218,785,155 State Share $72,063,102 $75,122,899 TOTAL COSTS OF APPROVED SCHIP PLAN $283,044,393 $293,908,054

co-payments and enrollment feeds do not generate “offsetting costs.” Enrollment fees are kept by the counties to partially compensate them for eligibility determination. No county participation is required in the NC Health Choice benefits payment. Co-payments are kept by providers who are then paid at a reduced rate by the claims payer. (For example, physicians keep co-pays paid to them, pharmacists keep co-payments made to them and hospitals keep co-pays paid to them.) During federal fiscal year 2004, a total of $2,079,317.79 was collected by counties in enrollment fees. Providers collected $234,194.31 in co-payments from those at or below 150% FPL (beginning February 2004) and $2,067,374.27 from those from 151% to 200% FPL.

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

Effective Date:

Approval Date: 58 Section 10. Annual Reports and Evaluations (Section 2108)

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

10.1.1.

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

10.2.

The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3.

The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

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

Effective Date:

Approval Date: 59 Section 11. Program Integrity (Section 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue to Section 12.

11.1

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

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related information) 11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.

Section 1128A (relating to civil monetary penalties) 11.2.5.

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

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

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

Effective Date:

Approval Date: 60 Section 12. Applicant and enrollee protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

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

Eligibility and Enrollment use the same services and systems as those used by the Title XIX program. Recipients receive their notices and options both verbally and in writing; expedited reviews are available at each step.

Health Services Matters

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

Health services matters use the same services and systems as those used by the State Health Plan as follows:

Two levels of internal review are available for Medical, Pharmacy, and Mental Health disputes. The first level review is by the Claims Processing Contractor. A written report is sent to the member, and if that review is not satisfactory to the member, the second is by a team coordinated by the CPC with medical specialty providers by phone.

The third level review can be made at the choice of the complainant to the Department of Insurance, the State Plan Administrator and Board or an outside medical consultant.

Each level generally requires written response within a maximum of 60 days, however, expedited reviews are available. These substantially shorten the time taken for a decision.

If the individual complainant still has unresolved issues after the process, the member may take the matter up with the Managed Care Patient Assistant Program in the NC Department of Justice. NC law specifically includes both the State Employees Health Plan and the NC Health Choice program included under this jurisdiction.

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

Effective Date:

Approval Date: 61

Recipients receive their notices and options both verbally and in writing; expedited reviews are available at each step.

Premium Assistance Programs

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

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NORTH CAROLINA TITLE XXI PROGRAM FACT SHEET

Name of Plan:

North Carolina CHIP Program

Plan Submitted: May 14, 1998 Plan Approved: July 14, 1998 Plan Effective Date: October 1, 1998

Amendment #1 Submitted: October 21, 1998 Amendment #1 Approved: January 15, 1999 Amendment #1 Effective: September 30, 1998

Amendment #2 Submitted: March 26, 1999 Amendment #2 Approved: June 23, 1999 Amendment #2 Effective: March 12, 1999

Amendment #3 Submitted: July 12, 1999 Amendment #3 Approved: September 30, 1999 Amendment #3 Effective: July 1, 1999

Amendment #4 Submitted: August 3, 2000 Amendment #4 Approved: October 19, 2000 AI/AN Cost Share Exemption Effective: May 1, 2000 Special Needs Children Effective: October 1, 2000

Amendment #5 Submitted: November 21, 2000 Amendment #5 Approved: February 16, 2001 Amendment #5 Effective: January 1, 2001

Amendment #6 Submitted: October 12, 2001 Amendment #6 Approved: January 9, 2002 Amendment #6 Effective: October 8, 2001

Amendment #7 Submitted: March 1, 2005 Amendment #7 Approved: June 30, 2005 Amendment #7 Effective: August 24, 2001 and February 1, 2004

Amendment #8 Submitted: February 28, 2006 Amendment #8 Approved: May 10, 2006 Amendment #8 Effective: January 1, 2006

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Background

• On May 14, 1998, North Carolina submitted its Title XXI State plan, which created a separate State health insurance program to provide coverage to uninsured children whose family income does not exceed 200 percent of the Federal poverty level (FPL). Enrollees whose annual income increases above 200 percent of the FPL to 225 percent of the FPL will be allowed to buy into the program for one year at full cost.

Title XXI Amendments

• North Carolina submitted its first amendment request on October 21, 1998. This amendment reflected State legislation amending the definition of "uninsured" so that the State's required period of uninsurance would not apply to children who had coverage through the Caring Foundation, which coverage had ceased. This amendment was approved on January 15, 1999.

• North Carolina submitted a second amendment on March 26, 1999. This amendment reflected the change in North Carolina General Statute, which expands the acceptable sites for the delivery of clinic services to include School-Based Health Centers. This amendment was approved on June 23, 1999.

• North Carolina submitted a third amendment on July 12, 1999. This amendment reflected changes in North Carolina's General Statute, which allowed the expansion of the dental services benefit by providing fluoride applications, sealants, simple extractions, therapeutic pulpotomies, and prefabricated stainless steel crowns. This amendment was approved on September 30, 1999.

• North Carolina submitted its fourth amendment on August 3, 2000. This amendment eliminated cost sharing for documented Native Americans and exempted special needs children from the 2-month waiting period of uninsurance required for program eligibility if health insurance benefits have been terminated due to a long-term disability or substantial reduction in or limitation of lifetime medical benefits or benefit category. This amendment was approved on October 19, 2000.

• North Carolina submitted its fifth amendment on November 21, 2000. This amendment established a freeze on new program enrollment effective January 1, 2001, at which time enrollment was approximately 72,000. North Carolina lifted the freeze on new enrollment effective October 8, 2001.

• North Carolina submitted its sixth amendment on October 12, 2001. This amendment reopens the program to all eligible enrollees by ending the active waiting list effective October 8, 2001. The amendment also eliminates the 60-day period of uninsurance currently called for in the State's Title XXI plan.

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• North Carolina submitted its seventh amendment on March 1, 2005. This amendment updates and amends the CHIP state plan to indicate compliance with the final CHIP regulations. The amendment also changes cost sharing for prescription drugs.

• North Carolina submitted its eighth amendment on February 28, 2006. This amendment creates a title XXI Medicaid Expansion Program for children from birth through age 5 with family income up to 200 percent of the Federal poverty level (FPL), and will move children in this age range from their current separate CHIP into this Medicaid expansion; delivers services to children in the Medicaid expansion through the Medicaid primary care case management delivery system; limits enrollment in the State’s separate SCHIP to children ages 6 through 18 years with family income up to 200 percent of the FPL; limits enrollment growth in the separate CHIP to three percent every 6 months (enrollment on January 1, 2006 was 104,835); establishes notification requirements for implementation of an enrollment cap; and creates a computer-based waiting list for new applicants whose applications cannot be approved because of the enrollment cap.

Children Covered Under the Program

• The State reported that 251,653 children were ever enrolled in CHIP in FFY 2008.

Administration and Phases

• The program is managed through the North Carolina Department of Health and Human Services. The State Employees Health Plan administers benefits and claims processing. Local departments of social services make eligibility determinations.

Health Care Delivery System

• The delivery system for children in the Medicaid expansion program is Medicaid primary care case management delivery system.

• The delivery system for children in the separate child health program is fee for service with some managed care options. Optional Prepaid Health Plans (Health Maintenance Organizations) are available under the State Employees Health Plan, but require additional premium contributions. These plans can choose to eliminate these additional premiums, and therefore participate in Title XXI.

Benefit Package

• Children in the Medicaid expansion program receive the North Carolina Medicaid benefit package.

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• The benefit package for children in the separate child health program is the State employee coverage provided through the State Employees Health Plan, plus Medicaid-equivalent benefits for Special Needs Children. Dental, optical, and hearing services are also provided.

Cost Sharing

• Families with incomes between 150 and 200 percent of the FPL will be required to pay a $50 enrollment fee for one child or $100 per family for two or more children.

• Families with incomes at or below 150 percent of the FPL will be required to pay the following copayments: $1 for generic drugs, $1 for brand drugs when no generic is available, and $3 for brand drugs when a generic is available. Total copayments will not exceed $14 per family per month.

• Families with incomes above 150 percent of the FPL will be required to pay the following copayments: $1 for generic drugs, $1 for brand drugs when no generic is available, and $10 for brand drugs when a generic is available; $5 for physician visits, clinic visits, dental visits, outpatient hospital visits and optometry visits (with the exception of preventative services for which there will be no copayment); and $20 for unnecessary emergency room use. Total cost sharing will not exceed the statutory cap of 5 percent of gross annual income.

• The Division of Medical Assistance will notify the State Employees Health Plan, through the eligibility information system (EIS), of the limit to the amount of copayments a child may have in order to ensure that the annual aggregate cost sharing for a family does not exceed 5 percent of the family's annual income. The State Employees Health Plan will track the amount of copayments paid by a family and will notify the family when that limit has been met. Families can then take the notification on visits to providers so that they are not charged further copayments.

Coordination between NC Health Choice with Medicaid

• The State uses the same eligibility determination mechanism for both Medicaid and CHIP. Eligibility determinations are made by local departments of social services. During the application process, the existing Title XIX EIS is queried to ascertain if the child has Medicaid coverage. If not, the application is first processed for Title XIX eligibility. Should the child be determined ineligible, then Title XXI eligibility is pursued.

Crowd-Out Strategy

• The applicant must not be covered under any private or employer-sponsored, creditable health insurance plan on the date of enrollment into the program. Cases that qualify due to dropping private insurance will be electronically coded so the

5

state may determine if the “crowd out” rate is impacted. Each case is processed through a system to match the family to the primary insurance providers in North Carolina. In addition, the claims processor runs periodic screens to double check the child’s insurance coverage. If creditable insurance coverage is found, the claim is denied.

Outreach Strategy

• Outreach is coordinated at the State level through existing public/private partnerships, particularly through collaborative implementation efforts between local departments of health and social services. The statewide guidance for this effort is provided through a committee co-chaired by the Division of Medical Assistance and the Division of Women and Children's Health.

Financial Information

Total FFY’ 09 SCHIP Allotment - $241,660,100 FFY ’09 Enhanced Federal Matching Rate – 75.22%

Date last updated: CMS, CMSO, FCHPG, DSCHI, September 1, 2009

_____________________________________________________________________________ Table of Contents State/Territory Name: North Carolina State Plan Amendment (SPA) #: NC-13-0008 This file contains the following documents in the order listed: 1) SPA Summary Form 2) Approval Letter 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan The complete title XXI state plan for North Carolina consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NC.0436.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: North Carolina State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NC-13-0008 Type of SPA:  MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2110(b)(2)(B) and (b)(6) of the SSA Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/02/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Teresa Smith Last Revision Date: Jan 7, 2014 Submit Date: Oct 18, 2013 Character Count:38 out of 2000   MAGI-CHIP Eligibility Methods-Bucket 1 Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/02/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

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

7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

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

Children and Adults Health Programs Group

JAN 15 2014

Sandra Terrell, MS, RN

North Carolina Department of Health and Human Services Acting Chief Operating Officer, Division of Medical Assistance 1985 Umstead Drive

Raleigh, NC 27603

Dear Ms. Terrell:

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPAs) numbered NC-13-0008, NC-13-0009 and NC-13-0012 submitted on October 18, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligibility have been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

SPA number NC-13-0008 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan.

A copy of the approved CS7 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan.

XXI Medicaid Expansion:

SPA number NC-13-0009 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan. :

Non-Financial Eligibility:

SPA number NC-13-0012 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, non-payment of premiums, and continuous eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of North Carolina’s current state plan as detailed below:

Page 2 — Ms. Sandra Terrell

New State Plan Page Impact on Current State Plan Section

CS17: Non-Financial Eligibility —- Residency Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security | Section 4.1.9.1 Number

CS21: Non-Payment of Premiums Section 8.7

C827: General Eligibility - Continuous Eligibility | Section 4.1.8

Your Title XXI project officer is Ms. LaVern Baty. She is available to answer questions concerning this amendment. Ms. Baty’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services

7500 Security Boulevard, Mail Stop $2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Baty and Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region 4, Division of Medicaid and Children’s Health Operations. Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Federal Center, 4" Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

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

Sincerely,

Eliot Fishman Director

Enclosures ce: Jackie Glaze, ARA, CMS Region IV Teresa Smith, Administrative Service Manager, Division of Medical Assistance

CHIP Eligibility

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

Separate Child Health Insurance Program Eligibility - Targeted Low-Income Children

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320

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

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

Must be under age 19.

Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

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

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

+ ile 19 133 211 x

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

Special Program for Children with Disabilities

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

PRA Disclosure Statement

JAN 15 2014

SPA# NC-13-0008 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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.20130709

JAN 15 2014

SPA# NC-13-0008 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

oe Oe

CEMs CHIP Eligibility

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

MAGI-Based Income Methodologies

te Child Health Insurance Program

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

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

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

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

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

Account for a reasonably predictable decrease in future income and/or family size.

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

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

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

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

An attachment is submitted.

PRA Disclosure Statement

JAN 15 2014

SPA# NC-13-0008 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number, The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# NC-13-0008 Approval Date: JAN i 5 2014

Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

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

Eligibility for Medicaid Expansion Program

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

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

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) + |jo 1 194 210 r 6 141 210 4 + Ile 19 107 133

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# NC-13-0009 Approval Date: JAN 1 5 2014

Effective Date: January 1, 2014 Page 1 of 1

CMs. CHIP Eligibility

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

42 CFR 457.320

Residency

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

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

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

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

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

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

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

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

[lA child who is a ward of the state regardless of where the child lives, or

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

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [i] A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

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

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

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

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

JAN 15 2014 SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 1 of 3

eRe

Cems

ETAMTEETORATDIGAN 6 ASTAEALD BEATE

CHIP Eligibility

One or more interstate agreement(s). Yes

J Alabama (1 Alaska

(1) Arizona

(C1 Arkansas (1 California (J Colorado (C] Connecticut (J Delaware (1) District of Columbia (1 Florida

1 Georgia 0 Hawaii

(Cl Idaho

CI Mlinois (C1 Indiana 1 Iowa

(1 Kansas

(Tl Kentucky (Louisiana (1 Maine

(1 Maryland (1) Massachusetts ( Michigan (1 Minnesota (O Mississippi (1 Missouri

[Bi] The state has interstate agreements with the following other states:

(1 Montana

(1 Nebraska

(] Nevada

[1 New Hampshire (1 New Jersey (1 New Mexico (1 New York

(0 North Carolina (7) North Dakota C1 ohio

(0) Oklahoma

(1) Oregon

( Pennsylvania

(7 Are in the state only for the purpose of attending school.

(0 Are out of the state only for the purpose of attending school.

[7] Retain addresses in both states.

(F) Other type of individual:

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

Provide a description of the policy:

(1) Rhode Island (C1 South Carolina C1 South Dakota [7] Tennessee (1 Texas

Utah

C1 Vermont

(CO Virginia

(1) Washington (0 West Virginia (1 Wisconsin (1 Wyoming

fl The interstate agreement contains a procedure for providing CHIP to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who: (Select all that apply)

An individual is a resident lives in NC independently from his parent(s) for his total financial support and care, including tuition and living expenses, does not intend to live with a parent that is a resident of another state, and is not claimed as a tax dependent by an individual who is a resident of another state.

SPA# NC-13-0012

PRA Disel

Approval Date:.

JAN 15 2014

Effective Date: January 1, 2014

Page 2 of 3

——ESE—Ere eee eee

CEMS. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB contro! number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 3 of 3

CHIP Eligibility

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

Separate Child Health Insurance Program (Non-Financial Eligibility - Citizenship

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

Citizenship

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

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

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the No verification process.

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. Yes

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:

The first day of the month of application if otherwise eligible.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing

in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). Yes

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

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program. 9 94g P94 JAN TS 2044 SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 1 of 3

CHIP Eligibility

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

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

[i] An individual is considered to be lawfully present in the United States if he or she is: 1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

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

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

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

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

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

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

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

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231,or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 1s 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)).

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 2 of 3

CHIP Eligibility

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number, The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 3 of 3

CHIP Eligibility

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

Separate Child Health Insurance Program

Non-Financial Eligibility - Social Security Number _

42 CFR 457.340(b)

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

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

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

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

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

How the state will use the SSN.

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

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

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

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

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

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

PRA Disclosure Statement

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page | of 2

CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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.

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

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

Separate Child Health Insurance Program INon-Financial Eligibility - Non-Payment of Premiums

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? No

The state assures that it provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page | of |

CHIP Eligibility

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

Separate Child Health Insurance Program |General Eligibility - Continuous Eligibility

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

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

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

@ For children up to age 19

C For children up to age

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

(@] Atthe end ofthe 12 | months continuous eligibility period.

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

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

[i] The child dies.

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

Other

Describe

| The child becomes eligible for SSI.

The child obtains comprehensive health insurance.

The child becomes incarcerated.

The child become eligible for WFFA/TANF.

+[ +] 4 [4] 4+ x | >< | >< | >< | x

The child becomes eligible for HSF/IAS.

JAN 1-5-2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

as The child becomes pregnant. x

- The child enters LTC/CAP

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130717

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: North Carolina State Plan Amendment (SPA) #: NC-13-0009 This file contains the following documents in the order listed: 1) SPA Summary Form 2) Approval Letter 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan The complete title XXI state plan for North Carolina consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NC.0437.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: North Carolina State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NC-13-0009 Type of SPA: MAGI Eligibility & Methods  XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2101(a)(2); 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/02/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Teresa Smith Last Revision Date: Dec 19, 2013 Submit Date: Oct 18, 2013 Character Count:373 out of 2000   This optional state plan indicates North Carolina elects to cover uninsured children who meet the definition of optional targeted low income children who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 457.320(a)(2) and (3). North C li th hild th th MICI b fi i i Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/02/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

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

7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

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

Children and Adults Health Programs Group

JAN 15 2014

Sandra Terrell, MS, RN

North Carolina Department of Health and Human Services Acting Chief Operating Officer, Division of Medical Assistance 1985 Umstead Drive

Raleigh, NC 27603

Dear Ms. Terrell:

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPAs) numbered NC-13-0008, NC-13-0009 and NC-13-0012 submitted on October 18, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligibility have been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

SPA number NC-13-0008 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan.

A copy of the approved CS7 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan.

XXI Medicaid Expansion:

SPA number NC-13-0009 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan. :

Non-Financial Eligibility:

SPA number NC-13-0012 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, non-payment of premiums, and continuous eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of North Carolina’s current state plan as detailed below:

Page 2 — Ms. Sandra Terrell

New State Plan Page Impact on Current State Plan Section

CS17: Non-Financial Eligibility —- Residency Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security | Section 4.1.9.1 Number

CS21: Non-Payment of Premiums Section 8.7

C827: General Eligibility - Continuous Eligibility | Section 4.1.8

Your Title XXI project officer is Ms. LaVern Baty. She is available to answer questions concerning this amendment. Ms. Baty’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services

7500 Security Boulevard, Mail Stop $2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Baty and Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region 4, Division of Medicaid and Children’s Health Operations. Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Federal Center, 4" Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

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

Sincerely,

Eliot Fishman Director

Enclosures ce: Jackie Glaze, ARA, CMS Region IV Teresa Smith, Administrative Service Manager, Division of Medical Assistance

CHIP Eligibility

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

Separate Child Health Insurance Program Eligibility - Targeted Low-Income Children

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320

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

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

Must be under age 19.

Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

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

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

+ ile 19 133 211 x

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

Special Program for Children with Disabilities

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

PRA Disclosure Statement

JAN 15 2014

SPA# NC-13-0008 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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.20130709

JAN 15 2014

SPA# NC-13-0008 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

oe Oe

CEMs CHIP Eligibility

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

MAGI-Based Income Methodologies

te Child Health Insurance Program

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

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

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

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

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

Account for a reasonably predictable decrease in future income and/or family size.

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

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

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

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

An attachment is submitted.

PRA Disclosure Statement

JAN 15 2014

SPA# NC-13-0008 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number, The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# NC-13-0008 Approval Date: JAN i 5 2014

Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

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

Eligibility for Medicaid Expansion Program

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

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

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) + |jo 1 194 210 r 6 141 210 4 + Ile 19 107 133

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# NC-13-0009 Approval Date: JAN 1 5 2014

Effective Date: January 1, 2014 Page 1 of 1

CMs. CHIP Eligibility

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

42 CFR 457.320

Residency

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

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

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

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

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

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

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

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

[lA child who is a ward of the state regardless of where the child lives, or

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

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [i] A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

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

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

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

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

JAN 15 2014 SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 1 of 3

eRe

Cems

ETAMTEETORATDIGAN 6 ASTAEALD BEATE

CHIP Eligibility

One or more interstate agreement(s). Yes

J Alabama (1 Alaska

(1) Arizona

(C1 Arkansas (1 California (J Colorado (C] Connecticut (J Delaware (1) District of Columbia (1 Florida

1 Georgia 0 Hawaii

(Cl Idaho

CI Mlinois (C1 Indiana 1 Iowa

(1 Kansas

(Tl Kentucky (Louisiana (1 Maine

(1 Maryland (1) Massachusetts ( Michigan (1 Minnesota (O Mississippi (1 Missouri

[Bi] The state has interstate agreements with the following other states:

(1 Montana

(1 Nebraska

(] Nevada

[1 New Hampshire (1 New Jersey (1 New Mexico (1 New York

(0 North Carolina (7) North Dakota C1 ohio

(0) Oklahoma

(1) Oregon

( Pennsylvania

(7 Are in the state only for the purpose of attending school.

(0 Are out of the state only for the purpose of attending school.

[7] Retain addresses in both states.

(F) Other type of individual:

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

Provide a description of the policy:

(1) Rhode Island (C1 South Carolina C1 South Dakota [7] Tennessee (1 Texas

Utah

C1 Vermont

(CO Virginia

(1) Washington (0 West Virginia (1 Wisconsin (1 Wyoming

fl The interstate agreement contains a procedure for providing CHIP to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who: (Select all that apply)

An individual is a resident lives in NC independently from his parent(s) for his total financial support and care, including tuition and living expenses, does not intend to live with a parent that is a resident of another state, and is not claimed as a tax dependent by an individual who is a resident of another state.

SPA# NC-13-0012

PRA Disel

Approval Date:.

JAN 15 2014

Effective Date: January 1, 2014

Page 2 of 3

——ESE—Ere eee eee

CEMS. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB contro! number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 3 of 3

CHIP Eligibility

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

Separate Child Health Insurance Program (Non-Financial Eligibility - Citizenship

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

Citizenship

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

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

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the No verification process.

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. Yes

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:

The first day of the month of application if otherwise eligible.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing

in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). Yes

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

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program. 9 94g P94 JAN TS 2044 SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 1 of 3

CHIP Eligibility

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

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

[i] An individual is considered to be lawfully present in the United States if he or she is: 1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

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

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

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

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

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

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

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

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231,or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 1s 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)).

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 2 of 3

CHIP Eligibility

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number, The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 3 of 3

CHIP Eligibility

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

Separate Child Health Insurance Program

Non-Financial Eligibility - Social Security Number _

42 CFR 457.340(b)

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

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

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

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

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

How the state will use the SSN.

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

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

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

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

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

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

PRA Disclosure Statement

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page | of 2

CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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.

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

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

Separate Child Health Insurance Program INon-Financial Eligibility - Non-Payment of Premiums

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? No

The state assures that it provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page | of |

CHIP Eligibility

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

Separate Child Health Insurance Program |General Eligibility - Continuous Eligibility

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

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

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

@ For children up to age 19

C For children up to age

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

(@] Atthe end ofthe 12 | months continuous eligibility period.

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

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

[i] The child dies.

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

Other

Describe

| The child becomes eligible for SSI.

The child obtains comprehensive health insurance.

The child becomes incarcerated.

The child become eligible for WFFA/TANF.

+[ +] 4 [4] 4+ x | >< | >< | >< | x

The child becomes eligible for HSF/IAS.

JAN 1-5-2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

as The child becomes pregnant. x

- The child enters LTC/CAP

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130717

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: North Carolina

State Plan Amendment (SPA) #: NC-13-0011-MC

This file contains the following documents in the order listed:

1) SPA Summary Form 2) Approval Letter 3) Approved SPA Pages

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

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NC.0438.R00.00 - Oct 01, 2013 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: North Carolina State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NC-13-0011 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group  Eligibility Processing Non-Financial Eligibility Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(3) & 2107(e)(1)(O) of the SSA; 42 CFR 457, subpart C; 457.110 Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/03/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Teresa Smith Last Revision Date: Oct 15, 2014 Submit Date: Oct 18, 2013 Character Count:459 out of 2000   This mandatory state plan addresses the new federal streamlined application and the processes for submitting an application. The streamlined application is for determining eligibility for MAGI based programs which indicates NCHC as well as most of the Family and Children's Medicaid programs. Applications may be b itt d b th f d l St t i t t b it il Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/03/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services CM Ss 7500 Security Boulevard, Mail Stop: $2-26-12

Baltimore, Maryland 21244-1850 CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

FEB 1 1 204

Sandra Terrell, MS, RN

NC Department of Health and Human Services

Acting Chief Operating Officer, Division of Medical Assistance 1985 Umstead Drive

Raleigh, NC 27603

Dear Ms. Terrell:

I am pleased to inform you that North Carolina’s Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), NC 13-0011-MC, submitted on October, 18, 2013, has been approved. This SPA incorporates the MAGI-based eligibility process requirements in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

Until February 1, 2014, the state is using an interim paper alternative single streamlined application. Until June 1, 2014, the state is using an interim online alternative single streamlined application. The state will implement revised alternative single streamlined paper and online applications that address CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the end of North Carolina’s approved CHIP State Plan:

® C824 e Attachment - Statement of use with respect to the alternative single streamlined online application e Attachment - Statement of use with respect to the alternative single streamlined paper application

This approval and the attachments supercede the following sections of the current CHIP State Plan:

e Section 4.3: Single, Streamlined Application Screen and Enroll Process e Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

Page 2 — Ms. Sandra Terrell

CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your Title XXI project officer is Ms. Lavern Baty. She is available to answer

questions concerning this amendment and other CHIP-related issues. Ms. Baty’s contact information is as follows:

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

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Baty

and to Ms. Jackie Glaze, Associate Regional Administrator (ARA) in our Atlanta Regional Office. Ms. Glaze’s address is:

Ms. Jackie Glaze

Office of the Regional Administrator Atlanta Federal Center

61 Forsyth Street, SW, Suite 4T20 Atlanta, Georgia 30303-8909

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

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

Sincerely,

Eliot Fishman Director

ce: Ms. Jackie Glaze, ARA, CMS Region IV, Atlanta

DEPARTMENT OF HEALTH & HUMAN SERVICES — Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: 2-26-12

Baltimore, Maryland 21244-1850 CENTER FOR MEDIGATD & CHIP SERVICES

Children and Adults Health Programs Group

Sandra Terrell, MS, RN

NC Department of Health and Human Services

Acting Chief Operating Officer, Division of Medical Assistance 1985 Umstead Drive

Raleigh, NC 27603

Dear Ms. Terrell:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of North Carolina’s Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA), NC 13-0011, submitted on October 18, 2013. Our review of this submission included a review of the online alternative single streamlined application developed by the state, and the following alternative paper based applications — a family and single individual Financial Assistance (FA) paper application, and the Appendix A and Appendix B attachments for these applications. Since the state’s application materials are the same for both Medicaid and CHIP, this letter is identical to the Medicaid companion letter.

Until February 1, 2014 the state is using an interim alternative paper single streamlined application. Until June 1, 2014 the state is using an interim alternative single streamlined online application. These interim applications need to be revised to reflect the following changes.

Date to complete

N : ecessary changes changes:

The state will remove the following questions from Appendix “Medicaid Family Planning”:

Have you had your tubes tied, cut or burnt?

Have you been sterilized by having any other medical procedure that would prevent you from having a baby? Have you had a vasectomy?

Have you been sterilized by having any other medical procedure that would prevent you from fathering baby?

2/1/2014

Page 2 — Ms. Sandra Terrell

Date to complete changes:

Necessary changes:

1. The application will not ask non-applicant household members a question about state residency. 6/1/2014

2. The application will not ask for the amount of Supplemental 1/27/2014 Security Income received.

3. The wording of the question about primary care provider will let applicants know that the choice being made is for Medicaid/CHIP only, and that there will be a separate plan 3/1/2014 selection process if they are eligible for coverage through the Marketplace.

4. The application will ask applicants who appear ineligible for Medicaid and CHIP about their access to employer sponsored 6/1/2014 health coverage.

Please submit the revised alternative paper application to CMS no later than February 1, 2014. Please submit the revised online application to CMS for review no later than May 1, 2014 to ensure approval by June 1, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Victoria Collins at

Victoria.Collins@cms.hhs.gov or (410) 786-2167.

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

Sincerely,

ride Yble

Linda Nablo Director, Division of State Coverage Programs

cc: Ms. Jackie Glaze, ARA, CMS Region IV, Atlanta

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

0 Paper Application [x] Online Application TRANSMITTAL NUMBER: STATE: NC 13-0011 North Carolina

Through June 1, 2014 the state is using an interim alternative single streamlined application. After June 1, 2014 the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

ExlPaper Application OOnline Application

TRANSMITTAL NUMBER: STATE:

NC 13-0011 North Carolina

Through February 1, 2014, the state is using an interim alternative single streamlined application. After February 1, 2014 the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

CHIP Eligibility

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

2102(b\(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

Application Processing

Indicate which application the agency uses for individuals apply ing for coverage who may be eligible based on the applicable modified adjusted gross income standard:

oO The single, streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act.

An alternative single, streamlined application developed by the state and approved by the Secretary in accordance with

x section 1413(b)(1)(B) of the Affordable Care Act.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the (0 agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

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 CF R 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means.

Other electronic means:

Name of method Description

acsimile

Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial application. periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low- income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for other insurance affordability programs.

Procedures include:

FEB 1 1 2044

SPA# NC-13-0011 Approval Date: Effective Date: October 1, 2013

Page 1 of 2

CHIP Eligibility

iw Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability programs; and

ml Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

ii Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single streamlined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced

premium tax credits in accordance with section 1943(b)(2) of the SSA. No

Redetermination Processing

Redeterm inations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343:

[Mf Once every 12 months.

im Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency.

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additio nal [Ml information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42

CFR 457.348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering

insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42 oO se]

CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for

CHIP.

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the O requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130917

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SPA# NC-13-0011 Approval Date: Effective Date: October 1, 2013 Page 2 of 2

_____________________________________________________________________________

Table of Contents

State/Territory Name: North Carolina

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

This file contains the following documents in the order listed:

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

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

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NC.0439.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: North Carolina Transmittal Number: NC-13-0012 Children's Health Insurance Program Eligibility: General Information General Information: Submission Title: short (under 100 characters) label used to identify this submission in the web application Non-Financial Eligibility Bucket 5 FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 1 of 1 Children's Health Insurance Program Eligibility: General Infor... 09/03/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/pag...

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

7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

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

Children and Adults Health Programs Group

JAN 15 2014

Sandra Terrell, MS, RN

North Carolina Department of Health and Human Services Acting Chief Operating Officer, Division of Medical Assistance 1985 Umstead Drive

Raleigh, NC 27603

Dear Ms. Terrell:

Iam pleased to inform you that your Title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPAs) numbered NC-13-0008, NC-13-0009 and NC-13-0012 submitted on October 18, 2013 and related to Modified Adjusted Gross Income (MAGI) Eligibility have been approved with an effective date of January 1, 2014.

MAGI Eligibility & Methods:

SPA number NC-13-0008 provides assurance on page CS15 that the state will apply methodologies based on MAGI for all separate CHIP covered groups; and using the approved MAGI conversion plan income thresholds, the state indicates on page CS7 that it will cover targeted low-income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan.

A copy of the approved CS7 is attached and supersedes the current Geographic Area, Age and Income Sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan.

XXI Medicaid Expansion:

SPA number NC-13-0009 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan. :

Non-Financial Eligibility:

SPA number NC-13-0012 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, non-payment of premiums, and continuous eligibility. Copies of the approved state plan pages are attached and these approved pages supersede sections of North Carolina’s current state plan as detailed below:

Page 2 — Ms. Sandra Terrell

New State Plan Page Impact on Current State Plan Section

CS17: Non-Financial Eligibility —- Residency Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security | Section 4.1.9.1 Number

CS21: Non-Payment of Premiums Section 8.7

C827: General Eligibility - Continuous Eligibility | Section 4.1.8

Your Title XXI project officer is Ms. LaVern Baty. She is available to answer questions concerning this amendment. Ms. Baty’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services

7500 Security Boulevard, Mail Stop $2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Baty and Ms. Jackie Glaze, Associate Regional Administrator, Centers for Medicare & Medicaid Services, Region 4, Division of Medicaid and Children’s Health Operations. Ms. Glaze’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Federal Center, 4" Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

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

Sincerely,

Eliot Fishman Director

Enclosures ce: Jackie Glaze, ARA, CMS Region IV Teresa Smith, Administrative Service Manager, Division of Medical Assistance

CHIP Eligibility

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

Separate Child Health Insurance Program Eligibility - Targeted Low-Income Children

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320

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

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

Must be under age 19.

Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

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

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

+ ile 19 133 211 x

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

Special Program for Children with Disabilities

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

PRA Disclosure Statement

JAN 15 2014

SPA# NC-13-0008 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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.20130709

JAN 15 2014

SPA# NC-13-0008 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

oe Oe

CEMs CHIP Eligibility

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

MAGI-Based Income Methodologies

te Child Health Insurance Program

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

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

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

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

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

Account for a reasonably predictable decrease in future income and/or family size.

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

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

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

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

An attachment is submitted.

PRA Disclosure Statement

JAN 15 2014

SPA# NC-13-0008 Approval Date: Effective Date: January 1, 2014

Page 1 of 2

CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number, The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# NC-13-0008 Approval Date: JAN i 5 2014

Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

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

Eligibility for Medicaid Expansion Program

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

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

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) + |jo 1 194 210 r 6 141 210 4 + Ile 19 107 133

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# NC-13-0009 Approval Date: JAN 1 5 2014

Effective Date: January 1, 2014 Page 1 of 1

CMs. CHIP Eligibility

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

42 CFR 457.320

Residency

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

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

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

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

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

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

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

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

[lA child who is a ward of the state regardless of where the child lives, or

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

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [i] A non-institutionalized pregnant woman who is living in the state and: 1. Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

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

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

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

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

JAN 15 2014 SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 1 of 3

eRe

Cems

ETAMTEETORATDIGAN 6 ASTAEALD BEATE

CHIP Eligibility

One or more interstate agreement(s). Yes

J Alabama (1 Alaska

(1) Arizona

(C1 Arkansas (1 California (J Colorado (C] Connecticut (J Delaware (1) District of Columbia (1 Florida

1 Georgia 0 Hawaii

(Cl Idaho

CI Mlinois (C1 Indiana 1 Iowa

(1 Kansas

(Tl Kentucky (Louisiana (1 Maine

(1 Maryland (1) Massachusetts ( Michigan (1 Minnesota (O Mississippi (1 Missouri

[Bi] The state has interstate agreements with the following other states:

(1 Montana

(1 Nebraska

(] Nevada

[1 New Hampshire (1 New Jersey (1 New Mexico (1 New York

(0 North Carolina (7) North Dakota C1 ohio

(0) Oklahoma

(1) Oregon

( Pennsylvania

(7 Are in the state only for the purpose of attending school.

(0 Are out of the state only for the purpose of attending school.

[7] Retain addresses in both states.

(F) Other type of individual:

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

Provide a description of the policy:

(1) Rhode Island (C1 South Carolina C1 South Dakota [7] Tennessee (1 Texas

Utah

C1 Vermont

(CO Virginia

(1) Washington (0 West Virginia (1 Wisconsin (1 Wyoming

fl The interstate agreement contains a procedure for providing CHIP to individuals pending resolution of their residency status and criteria for resolving disputed residency of individuals who: (Select all that apply)

An individual is a resident lives in NC independently from his parent(s) for his total financial support and care, including tuition and living expenses, does not intend to live with a parent that is a resident of another state, and is not claimed as a tax dependent by an individual who is a resident of another state.

SPA# NC-13-0012

PRA Disel

Approval Date:.

JAN 15 2014

Effective Date: January 1, 2014

Page 2 of 3

——ESE—Ere eee eee

CEMS. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB contro! number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 3 of 3

CHIP Eligibility

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

Separate Child Health Insurance Program (Non-Financial Eligibility - Citizenship

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

Citizenship

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

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

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the No verification process.

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. Yes

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:

The first day of the month of application if otherwise eligible.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing

in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). Yes

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

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program. 9 94g P94 JAN TS 2044 SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 1 of 3

CHIP Eligibility

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

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

[i] An individual is considered to be lawfully present in the United States if he or she is: 1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

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

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

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

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

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

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

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

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231,or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. 1s 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)).

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 2 of 3

CHIP Eligibility

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number, The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 3 of 3

CHIP Eligibility

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

Separate Child Health Insurance Program

Non-Financial Eligibility - Social Security Number _

42 CFR 457.340(b)

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

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

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or Individuals who are issued an SSN only for a valid non-work purpose.

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

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

How the state will use the SSN.

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

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

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

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

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

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

PRA Disclosure Statement

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page | of 2

CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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.

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

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

Separate Child Health Insurance Program INon-Financial Eligibility - Non-Payment of Premiums

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? No

The state assures that it provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page | of |

CHIP Eligibility

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

Separate Child Health Insurance Program |General Eligibility - Continuous Eligibility

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

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

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

@ For children up to age 19

C For children up to age

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

(@] Atthe end ofthe 12 | months continuous eligibility period.

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

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

[i] The child dies.

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

Other

Describe

| The child becomes eligible for SSI.

The child obtains comprehensive health insurance.

The child becomes incarcerated.

The child become eligible for WFFA/TANF.

+[ +] 4 [4] 4+ x | >< | >< | >< | x

The child becomes eligible for HSF/IAS.

JAN 1-5-2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014 Page 1 of 2

CHIP Eligibility

as The child becomes pregnant. x

- The child enters LTC/CAP

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130717

JAN 15 2014

SPA# NC-13-0012 Approval Date: Effective Date: January 1, 2014

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_____________________________________________________________________________ Table of Contents State/Territory Name: North Carolina State Plan Amendment (SPA) #: NC-14-0002 This file contains the following documents in the order listed: 1) SPA Summary Form 2) Approval Letter 3) Approved SPA Pages The complete title XXI state plan for North Carolina consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility NC.0877.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: North Carolina State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. NC-14-0002 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion  Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.310(d) 2110(b) of the SSA, 2101(f) of the ACA Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/02/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Teresa Smith Last Revision Date: Apr 2, 2014 Submit Date: Mar 31, 2014 Character Count:175 out of 2000   In this state plan the state provides information as to how coverage will be provided for children ineligible for Medicaid as a result of the elimination of income disregards. Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/02/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services (CMs

7500 Security Boulevard, Mail Stop: S2-26-12 Cc M Ss CENTERS FOR MEDICARE & MEDICAID SERVICES

Baltimore, Maryland 21244-1850 Children and Adults Health Programs Group MAY 2 1 2014

CENTER FOR MEDICAID & CHIP SERVICES

Sandra Terrell, MS, RN

North Carolina Department of Health and Human Services Acting Chief Operating Officer, Division of Medical Assistance 1985 Umstead Drive

Raleigh, NC 27603

Dear Ms. Terrell:

I am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number NC-14-0002 submitted on March 31, 2014, and related to Modified Adjusted Gross Income (MAGI) Eligibility with an effective date of January 1, 2014.

SPA number NC-14-0002 describes the state’s plan to provide coverage in its separate CHIP, for children subject to Section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved CS14 is attached, and should be incorporated within a separate subsection under Section 4.1 of North Carolina’s approved CHIP state plan.

Your title XXI project officer is Ms. LaVern Baty. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Baty’s contact information is as follows:

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

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

E-mail: Lavern.Baty@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Baty and to Ms. Jackie Glaze, Associate Regional Administrator (ARA) in our Atlanta Regional Office. Ms. Glaze’s address is:

Page 2 — Ms. Sandra Terrell

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Atlanta Federal Center, 4" Floor

61 Forsyth Street, SW, Suite 4T20

Atlanta, GA 30303-8909

Congratulations on the approval. If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of State Coverage Programs at (410) 786-5920. We look forward to continuing to work with you and your staff.

Sincerely, Eliot Fishman Director Enclosure ce:

Ms. Jackie Glaze, ARA, CMS Region IV, Atlanta

CHIP Eligibility

OMB Control Number: 0938-1148

0/31

tion date: 014

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

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

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

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.3 10(d). Coverage for this population will cease when the last child protected

* from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

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

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

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their

first renewal applying MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or

below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who c would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore

covered in the separate CHIP.

(% FPL.

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for

* Medicaid (based on the 2013 Meditaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

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

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

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

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid program.

SPA# NC-14-0002 Approval Date:, MAY 2 1 2014 Effective Date: January 1, 2014 Page | of 2

(cms. CHIP Eligibility

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

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 1f you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form. please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# NC-14-0002 Approval Date: MAY 2 { 2014 Effective Date: January 1, 2014

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_____________________________________________________________________________ Table of Contents State/Territory Name: North Carolina State Plan Amendments (SPA) #: NC-17-0001-MHPA This file contains the following documents in the order listed: 1) Approval Letter 2) Approved State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-76 Baltimore, MD 27244-1850 Children and Adults Health Procrams Groun lvts CENIÉß rOß frltDlCAR[ &MtDlCAlD StRvlCtS cENlÊn Fon MEDtcAtD & CHtp StnVtCtS DEC 2 I 20t8 Mr. Dave Richard Deputy Secretary for Medical Assistance ATTN: Betty Staton 2501 Mail Service Center Raleigh, NC27699-2501 Dear Mr. Richard: Your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) NC- 17-0001-MHPA submitted on December 28,2017, with additional information submitted on December 2I,20I8, has been approved. Through this SPA, North Carolina implements mental health parity requirements to ensure that treatment limitations and financial requirements applied to mental health (MH) and substance use disorder (SUD) benefits are no more restrictive than those applied to medical/surgical (M/S) benefits. The state also makes technical edits to clariS cost settlement language. This SPA has an effective date of October 1,2017 with the exception of the changes highlighted below. Section 2103(c)(7)(A) of the Social Security Act (the Act), as implemented through regulations at 42 CFR 457.496(d)(3)-(5), requires states that provide both M/S and MH/SUD benefits to ensure that financial requirements and treatment limitations applied to MHiSUD benefits covered under the state child health plan are consistent with the mental health parity requirements of section 2705(a) of the Public Health Service Act, in the same manner that such requirements apply to a group health plan. North Carolina demonstrated compliance by providing the necessary assurances and supporting documentation that the state's application of financial requirements and quantitative and non-quantitative treatment limitations to MH/SUD benefits are consistent with section 2103(c)(l)(A) of the Act. In order to comply with parity requirements, the state is removing an ambulatory detoxification benefit with a low utilization rate and a quantitative limit for mobile crisis services. In addition, the state is changing an existing quantitative limit on multi-systemic therapy from a hard limit to a soft limit that can be exceeded when medically necessary. These changes are effective March l,20Ig. This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analy zed separately.

Page 2 - Mr. Dave Richards Your title XXI project officer is Ms. Cassie Lagorio. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Lagorio's contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services, Mail Stop S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-4554 E-mail: Cassandra.Lagorio@cms.hhs.gov Official communications regarding program matters should be sent simultaneously to Ms. Lagorio and to Ms. Shantrina Roberts, Associate Regional Administrator (ARA) in our Atlanta Regional Office. Ms. Roberts's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 If you have additional questions or concerns, please contact Ms. Amy Lutzky, Director, Division of State Coverage Programs, at (410) 786-0721. We look forward to continuing to work with you and your staff. ![; Director cc: Ms. Shantrina Roberts, ARA, CMS Region IV /signed Anne Marie Costello/

1 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM (Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b))) State/Territory: North Carolina (Name of State/Territory) As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR 457.40(b)) (Signature of Governor, or designee, of State/Territory, Date Signed) submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department. The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Mandy Cohen Position/Title: Secretary, NC DHHS Name: Dave Richard Position/Title: Deputy Secretary for Division of Medical Assistance Name: Beth Daniel Position/Title: CHIP Coordinator *Disclosure. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #34). The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

When submitting a State plan amendment, states should redline the changes that are being made to the SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

3 existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42 CFR 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

4 or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre-existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below: • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

5 eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

6 Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16 SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

7 Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements 1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70): Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI. 1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2)) North Carolina’s Title XXI Plan, the North Carolina Health Choice for Children (NCHC) Program, is a combination plan consisting of: a. Medicaid Expansion Groups with the following converted MAGI-equivalent income thresholds: i. Children ages 0 (newborn) through 12 months with family income from 194% up to and including 210% of Federal Poverty Level; ii. Children ages 13 months through 5 years with family income from 141% up to and including 210% of the Federal Poverty Level; and iii. Children ages 6 through 18 years with family income from 107% up to and including 133% of the Federal Poverty Level. The State enrolls children ages 0 through and including 18 residing in families with annual incomes as specified in Section 1.1.3 in the Title XXI Medicaid Expansion child health program. These children receive the same benefits as children enrolled under the Medicaid Title XIX program. As in the Medicaid program, these children may have other health insurance coverage. However, Medicaid is always the payer of last resort. SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

8 b. Separate Child Health Program: Uninsured children from ages 6 through 18 years (up to the last day of the month in which the beneficiary turns 19): • With converted MAGI-equivalent family income thresholds from above 133% up to and including 211% of the Federal Poverty Level; • Who do not qualify for Medicaid, Medicare, or other federal government sponsored health insurance; • Who are residents of North Carolina and eligible under Federal law; and • Who have paid the Program enrollment fee. 1.1-DS The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5)) 1.2. Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d)) 1.3. Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42 CFR 457.130) Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications). 1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date. Original Plan Effective Date: October 1, 1998 Implementation Date: October 1, 1998 SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

9 SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

10 • Transmittal Number SPA Group PDF # Description Superseded Plan S • NC-13-0008 • Effective/Implemen tation Date: January 1, 2014 MAGI Eligibility & Methods CS7 CS15 Eligibility – Targeted Low Income Children MAGI-Based Income Methodologies Supersedes the current sect Area 4.1.1; Age 4.1.2; and Incorporate within a separa under section 4.3 • NC-13-0009 • Effective/Impleme ntation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current M expansion section 4.0 • NC-14-0002 • Effective/Implemen tation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separa under section 4.1 • NC-13-0011 • Effective/Implemen tation Date: January 1, 2014 Eligibility Process CS24 Single, Streamlined Application Screen and Enroll Process Renewals Supersedes the current sect • NC-13-0012 • Effective/Implemen tation Date: January 1, 2014 Non-Financial Eligibility CS17 CS18 CS19 CS21 CS27 Non-Financial Eligibility – Residency Non-Financial – Citizenship Non-Financial – Social Security Number Non-Payment of Premiums Continuous Eligibility Supersedes the current sect Supersedes the current sect LR; 4.1.1-LR Supersedes the current sect Supersedes the current sect Supersedes the current sect SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

11 Superseding Pages of MAGI CHIP State Plan Material State: North Carolina SPA #15-0001 Purpose of SPA: The primary purpose of SPA #15-001 is to implement program eligibility changes to reflect Affordable Care Act and State legislative requirements. The North Carolina Legislature has not amended any legislation affecting program benefits or cost sharing since 2011. This SPA also documents the repeal of North Carolina’s CHIP buy-in program effective October 1, 2015. Proposed effective date: October 1, 2015 Proposed implementation date: October 1, 2015 SPA#17-0001 Purpose of SPA: This State Plan Amendment is to comply with updated template as well as to demonstrate compliance with Mental Health parity. The North Carolina Health Choice (NCHC) Program, is the only North Carolina (NC) benefit plan to which the final rule applies. The North Carolina Division of Medical Assistance (DMA) has completed an analysis of the NCHC benefit package and has determined that NC is compliant with the final rule. In addition to the changes above, the NCHC is authorized by this State Plan to reimburse at the Medicaid established rate for the provided services. Unless otherwise authorized within this section of the State Plan, Title XXI services are prospectively reimbursed and not subject to cost settlement. Proposed effective date: October 1, 2017 Proposed implementation date: October 1, 2017 SPA # 18-007 Purpose of SPA: To implement provisions for temporary adjustments to enrollment and redetermination policies and cost sharing requirements for children in families living and/or working in Governor declared or federally declared disaster areas or other areas as determined by the North Carolina Department of Health and Human Services. In the event of a natural disaster, the State will notify CMS that it intends to provide temporary adjustments to its enrollment and/or redetermination policies and cost sharing requirements, the effective and duration date of such adjustments, and the applicable Governor or FEMA declared disaster areas. Proposed effective date: September 13, 2018 Proposed implementation date: September 13, 2018 SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

12 1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved.

The North Carolina Department of Health and Human Services, Division of Medical Assistance, follows the same Tribal consultation process for the CHIP Program as it does for the State Medicaid Program. North Carolina received CMS approval on SPA 10-038 on March 17, 2011 to establish the Tribal consultation process which consists of a representative of the Eastern Band of Cherokee Indians sitting on the Medical Care Advisory Committee. The Advisory Committee meets at least quarterly to review activities of the Division of Medical Assistance and provide recommendations and advice on current and future policy initiatives and pending changes to the Medicaid and CHIP programs. During the development of this SPA and prior to submission to CMS:

• The State sought the Tribe’s advice and input on matters related to the changes to Medicaid and CHIP programs through the MCAC quarterly meeting. • The State Medicaid Agency also notified the Tribe in writing of these pending CHIP SPA changes via e-mail on April 6, 2015 providing details of the changes. • The tribe notified the Agency on April 6, 2015 that they were in agreement with the changes. • Please see attached in the SPA submission packet the CMS standard tribal questions/responses, the notification to the tribes, and the tribal notification back to the State.

TN No: 10-038 Approval Date: 03/17/2011Effective Date: 01/01/2011

Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description. • Population • Number of uninsured • Race demographics • Age Demographics • Info per region/Geographic information

SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

13 2.1. Describe the extent to which, and manner in which, children in the State (including targeted low- income children and other groups of children specified) identified , by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102(a)(1)); (42 CFR 457.80(a))

The North Carolina Health Choice for Children program serves all 100 counties across the State. The State screens and enrolls uninsured eligible children in the Medicaid expansion program and the separate Child Health Insurance Program based on family size, modified adjusted gross income (MAGI) as a percentage of the Federal Poverty Level (FPL %), and age.

According to the NC Institute of Medicine’s (NCIOM) 2013 Child Health Report Card, “More than 160,000 children in NC slipped into poverty during the recent recession, as the percentage of poor children increased from 19.5 percent of the child population in 2007 to 26 percent – more than one in every four children – in 2012.” However, the NCIOM reported that in a five-year period from 2007 to 2012, the percentage of uninsured children living under 200 percent of the FPL in NC decreased from 20.6 percent to 11.4 percent. Furthermore, the U.S. Census Bureau’s 2013 American Community Survey estimated the number of children in North Carolina under age 19 living below 200percent of the federal poverty level to be 1,164,000. Within this population, the number of children without health insurance and therefore potentially eligible for Title XIX or Title XXI healthcare programs was estimated at 105,000 or 9 percent.

In State Fiscal Year 2014, 124,097 children applied for NC Health Choice Program eligibility. The percentage of eligible children, by age, who applied for the NC Health Choice Program was 35 percent for ages 6 through 9; 39 percent for ages 10 – 14; and 26 percent for ages 15 through 18.

In State Fiscal Year 2014, here were over 67,000 (55%)White applicants; over 36,000 (30%) Black applicants; over 3,000 (2.5%) Asian applicants; over 1,000 (1.4%) American Indian/Alaska Native applicants. More than 14,000 (8.1%) applicants did not indicate their race on the application form. Section 5 of this State Plan describes the NC Health Choice Program’s specific outreach efforts for unique ethnic and racial groups.

For the first half of SFY2014, the average NC Health Choice [separate CHIP program] monthly enrollment was 155,539. After implementation of the Affordable Care Act CHIP Medicaid Expansion on January 1, 2014, the average NC Health Choice monthly enrollment through August 2014 was 80,825.

The purpose of North Carolina’s Title XXI plan is to ensure that every child in the state has access to an ongoing system of preventive health care. The program is designed to provide SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

14 comprehensive health care coverage for children of working families who make too much to qualify for Title XIX and too little to afford employer-sponsored health insurance or private insurance available through the Federally Facilitated Marketplace.

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)); (ARRA #2, CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice.

The NC DHHS Secretary has appointed a designated liaison in the Office of the Secretary to facilitate the intergovernmental relationship between the Department and the Eastern Band of the Cherokee Indians and any other Indian Health Program meeting the definition under the Act to assure compliance with the federal provisions for and to expedite communication and between these entities. To meet the requirements for timely notification of the Tribe for CHIP SPA submissions or other policy changes that arise between MCAC Quarterly meetings, the Division of Medical Assistance will notify the Tribe in writing of these pending changes. The State will use this combined approach to seek the Tribe’s advice and input on matters related to the changes to the Medicaid and CHIP programs. SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

15

Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4. Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed health care plans (including fully and partially capitated plans); contracts with indemnity health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems.

Should the State choose to cover unborn children under the Title XXI State plan, the State must describe how services are paid. For example, some states make a global payment for all unborn children while other states pay for services on fee-for-services basis. The State’s payment mechanism and delivery mechanism should be briefly described here.

Section 2103(f)(3) of the Act, as amended by section 403 of CHIPRA, requires separate or combination CHIP programs that operate a managed care delivery system to apply several provisions of section 1932 of the Act in the same manner as these provisions apply under title XIX of the Act. Specific provisions include: section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. If the State CHIP program operates a managed care delivery system, provide an assurance that the State CHIP managed care contract(s) complies with the relevant sections of section 1932 of the Act. States must submit the managed care contract(s) to the CMS Regional Office servicing them for review and approval.

In addition, states may use up to 10 percent of actual or estimated Federal expenditures for targeted low-income children to fund other forms of child health assistance, including contracts with providers for a limited range of direct services; other health services initiatives to improve children’s health; outreach expenditures; and administrative costs (See 2105(c)(2)(A)). Describe which, if any, of these methods will be used.

Examples of the above may include, but are not limited to: direct contracting with school- based health services; direct contracting to provide enabling services; contracts with health centers receiving funds under section 330 of the Public Health Service Act; contracts with hospitals such as those that receive disproportionate share payment adjustments under section 1886(d)(5)(F) or 1923 of the Act; contracts with other hospitals; and contracts with public health clinics receiving Title V funding. If applicable, address how the new arrangements under Title XXI will work with existing service delivery methods, such as regional networks for chronic illness and disability; neonatal care units, or early-intervention programs for at-risk infants, in the delivery and SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

16 utilization of services. (42 CFR 457.490(a))

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

Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act, including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS Regional Office for review and approval. (Section 2103(f)(3))

Potential new and returning applicants for the NC Health Choice Program are simultaneously screened by a county Department of Social Services (DSS) for eligibility in the State Medicaid Program at the time of application or re-application. This one-stop application process expedites eligibility determination and enrollment in either program. Another parallel between the State Medicaid Program and NC Health Choice is the use of the same claims processing vendor, Computer Sciences Corporation (CSC), as of July 1, 2013. This consolidation of claims processing under one vendor provides a standardized and efficient means of managing health services claims. Finally, beneficiaries in both the State Medicaid Program and NC Health Choice are assigned to a primary care provider medical home via the Community Care of North Carolina (CCNC) network within a primary care case management delivery system. 2011 State legislation mandated standardized requirements for Medicaid and Health Choice Provider applications, screenings, and enrollment.

Methods for Assuring Delivery Program eligibility is determined through the use of the aforementioned dual Medicaid and Health Choice application by county DSSs. The State transmits new, revised, and cancelled NC Health Choice beneficiary records nightly to the claims processor. Upon determination of an applicant’s eligibility and the collection of any applicable enrollment fee, the county eligibility specialist enters the new or renewal applicant’s eligibility and demographic information into the State eligibility and enrollment system. The claims processor creates an updated eligibility file with a unique member ID number and generates an annual ID card for each NC Health Choice beneficiary. The card contains the coverage effective date, primary care provider contact information, medical and pharmacy co-payment amounts, and toll-free numbers for providers requesting prior authorization, benefit limits, and claim filing information. The beneficiary must present the ID card when seeking services at a provider office, hospital inpatient or outpatient facilities, or pharmacy. The provider can then verify eligibility via web or phone verification with the claims processor. In the event of SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

17 an emergency for a beneficiary requiring medication, the claims processor has the authority to update beneficiary eligibility in the claims processing system manually for pharmacy Point-of-Sale verification.

The Division of Medical Assistance (DMA) funds and maintains an account to reimburse the claims processor for claim and administrative expenses, in addition to expenses from other contracts established for NC Health Choice program services. Additional vendor contracts include actuarial services, third party recovery and subrogation services, independent auditor services to monitor claims payment accuracy rates, eyewear (glasses & contacts) services, and behavioral health services utilization review.

Choice of Financing The NC Health Choice for Children Program is funded with federal funds in an enhanced Federal Medical Assistance Percentage ratio pursuant to the allotment to States in 42 USC § 1397dd and State appropriated funds.

Title XXI (Health Choice) services authorized by this State Plan are reimbursed at the Medicaid established rate for the provided service. Unless otherwise authorized within this section of the State Plan, Title XXI services are prospectively reimbursed and not subject to cost settlement.

Managed Care Health Choice program services are all reimbursed on a Fee-for-Service basis within a primary care case management health service delivery structure (which qualifies as managed care under 42 C.F.R. 457.10). NC Health Choice beneficiaries are linked to a primary care provider in the Community Care of North Carolina (CCNC) primary care case management network. This network ensures cost-effective health care access and utilization. The NC Department of Health and Human Services pays CCNC providers the same per member, per month fees allowed under the State Medicaid Program. Providers are also being reimbursed on a Fee-for-Service basis for services rendered to NC Health Choice beneficiaries.

Health Choice beneficiaries select or are assigned to a CCNC Medical Home primary care provider (PCP). That provider’s contact information appears on the beneficiary’s health insurance ID card. Beneficiaries are encouraged to make an appointment to get a medical history established with their PCP; beneficiaries must see the PCP for most health care services and obtain referrals to see other providers.

Pursuant to 42 U.S.C. 1397cc(f)(3) and 42 U.S.C. 1396u-2(1)(c), enrollment in CCNC is optional for federally recognized American Indian Medicaid and NC Health Choice beneficiaries whether or not they receive services through tribal facilities. SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

18 Beneficiaries may change primary care providers by contacting the Department of Social Services. Beneficiary rights and procedures for changing providers are the same as those for the State Medicaid Program. Beneficiaries may change providers during a review process, when the currently authorized provider goes out of business, and when the beneficiary is changing providers for another service with an authorization period of six months or more. The current authorization for services will transfer to the new provider within five (5) business days of notification by the new provider to the Division of Medical Assistance Fiscal Agent and upon submission of written attestation that provision of the service meets NC Health Choice policy and the beneficiary’s condition meets coverage criteria and acceptance of all associated responsibility; and either: a) Written permission of beneficiary or legal guardian for transfer; or b) a copy of a discharge from the previous provider. Authorization will be effective on the date that the new provider submits a copy of the written attestation. Prior to the end of the current authorization period, the new provider must submit a request for reauthorization of the service in accordance with the clinical coverage policy requirements and these procedures. Beneficiaries may change providers at any other time. However, the discharging provider and the new provider must follow all policy requirements and these procedures.

Effective October 1, 2015, North Carolina Health Choice hospital outpatient services, excluding laboratory services, for in-state hospitals shall be reimbursed at 70 percent (70%) of their allowable outpatient costs. North Carolina Health Choice allowable outpatient costs shall be determined using the CMS 2552 cost report, 42 CFR § 413, and the CMS Provider Reimbursement Manual. If a hospital’s interim NC Health Choice payments exceed the allowable outpatient cost for NC Health Choice services, the provider shall remit the difference at the time the cost report is filed. The Division shall return the federal share of the difference via the CMS 64 Report. If a hospital’s allowable outpatient cost for NC Health Choice services exceeds the NC Health Choice interim payments on the filed and accepted cost report, and subject to the availability of federal funds in the NC Health Choice allotment, the Division shall pay the difference to the provider and submit claims to the CMS for reimbursement of the federal share of that payment in the federal fiscal quarter following payment to the provider. No cost settlement payment shall be paid to the provider if funds in the NC Health Choice allotment are unavailable or insufficient to cover the federal share of the cost settlement.

Effective July 1, 2016, Local Health Departments shall be reimbursed their allowable costs for covered services, which are rendered to North Carolina Health Choice recipients. North Carolina Health Choice allowable costs for covered services shall be determined using the CMS approved cost report methodology in the Medicaid (Title XIX) State Plan, 42 CFR § 413, and the CMS Provider Reimbursement Manual. If a local health department’s interim NC Health Choice payments exceed the provider’s certified cost for NC Health Choice services, the provider shall remit the excess federal share of the overpayment at the time the cost report is filed. The Division shall return the federal share of the difference via the CMS 64 Report. If a local health department’s certified cost for NC Health Choice services exceeds the NC Health Choice interim payments on the filed and accepted cost report, and subject to the availability of funds in the NC SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

19 Health Choice allotment, the Division shall pay the federal share of the difference to the provider and submit claims to the CMS for reimbursement of that payment in the federal fiscal quarter following payment to the provider. No cost settlement payment shall be paid to the provider if funds in the NC Health Choice allotment are unavailable or insufficient to cover the federal share of the cost settlement.

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42 CFR 457.490(b))

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

The NC Health Choice for Children program uses utilization controls which include: a. requirements for medical necessity determination; b. prior approval requirements; c. benefit limitations; d. utilization management reporting; and e. fraud and abuse detection.

a. requirements for medical necessity determination All medical services performed must be medically necessary and may not be experimental in nature. Medical necessity is determined by generally accepted North Carolina community practice standards.

b. prior approval requirements Numerous Health Choice clinical coverage policies for medical, surgical, and mental health and substance abuse services require prior approval before a service may be provided. However, utilization review and prior approval treatment limitations are no more restrictive among the mental health and substance abuse services than they are among the medical and surgical services. Some prior approval requirements are recommended by the Physician Advisory Group (PAG), a non-profit organization that was created for the purpose of advising the North Carolina Department of Health and Human Services. SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

20 The PAG provides formal policy review and recommendations on new and existing medical coverage policies as part of a medical policy development process controlled by NC statutes. Prior approval serves to further ensure that services are only covered when medically necessary. Prior approval also allows the NC Health Choice Program to control service utilization and subsequently the cost of Program administration. This is particularly important since Health Choice is not an entitlement program and receives limited State-appropriated funding.

c. benefit limitations NC Session Law 2011-145 mandated that “Except as otherwise provided for eligibility, fees, deductibles, copayments, and other cost sharing charges, health benefits coverage provided to children eligible under the Program shall be equivalent to coverage provided for dependents under the North Carolina Medicaid Program except for the following: 1) No services for long-term care; 2) No non-emergency medical transportation; 3) No EPSDT; and 4) Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection.” NC Health Choice Program clinical coverage service restrictions and visit limits within clinical coverage policies are equivalent to the restrictions and limitations in the equivalent NC Medicaid Program clinical coverage policies. In the aggregate, the service restrictions and limitations help contain program administration costs.

d. utilization management reporting The DMA contract with its claims processing agent is in compliance with applicable statutes. DMA and its contractors also agree to prescriptive requirements for internal utilization review, provider and beneficiary monitoring, and performance standards. The Claims Processing Contractor utilization management reporting includes: trending; comparison to prior reporting periods; and changes in utilization amounts, costs by type of service, and provider practice patterns.

e. fraud and abuse detection The DMA Program Integrity Section works closely with NC Health Choice Utilization Review vendors regarding special investigations, provider site audits, identified third party resources, comprehensive insurance identified for Title XXI beneficiaries, and coordination of special projects.

North Carolina law contains provisions regarding beneficiaries’ fraudulent utilization of the NC Health Choice Program. One Health Choice eligibility requirement is being uninsured. N.C. GEN. STAT. § 108A- 70.21(a) requires that if any health insurance other than Health Choice is provided to a child after enrollment in the Program and prior to the expiration of the twelve-month eligibility period, the custodial parent must notify the Department within 10 days of receipt of the other health insurance. Finally, N.C. GEN. STAT. § 108A-70.28 contains provisions for the criminal prosecution of participants’ guardians who undertake any fraudulent misrepresentation relating to eligibility for or utilization of the NC Health Choice Program.

Section 4. Eligibility Standards and Methodology SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

21

Guidance: The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. Included on the template is a list of potential eligibility standards. Please check off the standards that will be used by the state and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, describe how they will be applied and under what circumstances they will be applied.

States electing to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan or combination plan should check the appropriate box and provide the ages and income level for each eligibility group. If the State is electing to take up the option to expand Medicaid eligibility as allowed under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as well as update the budget to reflect the additional costs if the state will claim title XXI match for these children until and if the time comes that the children are eligible for Medicaid.

4.0.

Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group:

NC uses Title XXI funding to expand Medicaid benefits to the following assistance categories based on family income in relation to the Federal Poverty Level:

1. Children 0 – 12 months of age with family income from 194% up to and including 210% of the federal poverty income level; 2. Children 13 months – 5 years of age with family income from 141% up to and including 210% of the federal poverty income level; and 3. Children 6-18 years of age with family income from 107% up to and including 133% of the federal poverty income level.

4.1.

Separate Program Check all standards that will apply to the State plan. (42 CFR 457.305(a) and 457.320(a))

4.1.0 Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option.

North Carolina has been conducting a daily, automated match with social security numbers provided on joint Medicaid and NC Health Choice eligibility applications since January of 2010. If an applicant claims to be a U.S. citizen, the DSS sends the Social Security number to the Social Security Administration (SSA) for a citizenship match. The average response time for a match through the SSA SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

22 is 24 to 48 hours.

4.1.1 Geographic area served by the Plan if less than Statewide:

4.1.2 Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group:

4.1.2.1-PC Age: through birth (SHO #02-004, issued November 12, 2002) Pursuant to N.C. GEN. STAT. § 108A 70.21(a)(1), all beneficiaries in the separate CHIP Program (NC Health Choice) must be 6 through and including 18 years of age.

4.1.3 Income of each separate eligibility group (if applicable):

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through % of the FPL (SHO #02-004, issued November 12, 2002) N.C. Health Choice beneficiaries receive benefits in the following assistance categories based on family income in relation to the Federal Poverty Level. • Income of above 133% up to and including 159% of the Federal Poverty Income Level; and • Income in excess of 159% up to 211% of the Federal Poverty Income Level.

Household income must be above Medicaid income guidelines and from above 133% and up to and including 211% of the federal poverty level (FPL). Countable household monthly income is determined using the same Modified Adjusted Gross Income (MAGI) guidelines as for Title XIX. Earned income is determined by review of provided pay stubs, copies of checks, business records for self-employment, or other written proof of income as requested. New applications require proof of income for the month prior to application. Renewal eligibility determinations require proof of income for the month prior to renewal review. Self-employment income is determined using a base period of 12 months immediately prior to application. Exceptions to the 12-month period use the same guidelines as Title XIX. Unearned income is determined using the same guidelines as Title XIX. The monthly income base period is the month prior to application or renewal review. The child support base period is six (6) months.

Family size is determined by the tax household under the MAGI rules for both Medicaid and NC Health Choice. Under MAGI rules, there is a 5% income disregard if an applicant lives in a household with an income too high to qualify for Medicaid eligibility. (Per CMS guidance and instructions, North Carolina applies the 5% disregard if income exceeds the NC Health Choice limit. The 5% disregard would have already been applied to the highest income limit Medicaid program available prior to evaluating for NC Health Choice).

4.1.4 Resources of each separate eligibility group (including any standards relating to spend downs and disposition of resources): SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

23

4.1.5 Residency (so long as residency requirement is not based on length of time in state):

Beneficiaries must be residents of North Carolina pursuant to N.C. GEN. STAT. § 108A 70.21(a)(1). State residency verification is controlled by N.C. GEN. STAT. § 108A-55.3.

4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility):

4.1.7 Access to or coverage under other health coverage:

Pursuant to N.C. GEN. STAT. § 108A 70.21(a)(1), an applicant is ineligible for the NC Health Choice program if he or she is insured or is eligible for Medicaid, Medicare, or other federal government sponsored insurance.

A child must be uninsured to be eligible for NC Health Choice. Uninsured means the applicant is not covered under any private or employer-sponsored creditable health insurance plan on the date of enrollment into the program and is ineligible for Medicaid, Medicare or other federal government sponsored insurance.

4.1.8 Duration of eligibility, not to exceed 12 months:

Pursuant to N.C. GEN. STAT. § 108A 70.21(a)(4), enrollment is continuous for one year. However, pursuant to N.C. GEN. STAT. § 108A 70.21(a)(3), if a beneficiary acquires health insurance other than (in addition to) the NC Health Choice Program after enrollment and prior to the expiration of the eligibility period of one year, then the beneficiary will be deemed to be insured and ineligible for continued coverage under the Program.

4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 42 CFR 457.310 and 457.320 that are not addressed above. For instance:

• Pursuant to 42 USC 1397jj(b)(2), targeted low-income children do not include inmates in a public institution and patients in an institution for mental diseases, as defined in 42 C.F.R. 435.1010, at the time of initial application for the Program or at the time of eligibility redetermination. • Applicants ineligible for the Medicaid Program solely because of a failure to comply with procedural requirements (e.g., proving required eligibility determination information) are not eligible for the Title XXI NC Health Choice Program.

Guidance: States may only require the SSN of the child who is applying for coverage. If SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

24 SSNs are required and the State covers unborn children, indicate that the unborn children are exempt from providing a SSN. Other standards include, but are not limited to presumptive eligibility and deemed newborns.

4.1.9.1

States should specify whether Social Security Numbers (SSN) are required. Program eligibility is determined through the use of a dual Medicaid and NC Health Choice application by a county DSS. Applications require a Social Security number for each child applying for health insurance coverage.

Guidance: States should describe their continuous eligibility process and populations that can be continuously eligible.

4.1.9.2 Continuous eligibility

The period of enrollment is twelve (12) continuous months from the date of initial enrollment. An increase in household income during the continuous enrollment period does not affect current enrollment. The eligibility worker only reviews household income during the annual renewal review to determine eligibility for a new 12-month enrollment period. However, if family income decreases during the continuous enrollment period, a family may request to apply for Medicaid eligibility. Exceptions to the 12-month continuous enrollment period that will result in coverage cancellation include: ● Child obtains comprehensive health insurance ● Child moves out of state ● Child is incarcerated ● Child becomes eligible for Work First/TANF ● Child is removed from household by DSS & placed in foster care (child is then enrolled into Medicaid) ● Child turns age 19 ● Child becomes eligible for SSI Medicaid ● Child becomes pregnant (child is then enrolled in Medicaid for Pregnant Women; see Section 6.2.9) ● Child dies ● Child enters Long Term Care ● Child’s family submits a voluntary request for termination ● County case workers are unable to locate the child SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

25 On September 18, 2015, Session Law 2015-241, Appropriations Act of 2015 (State budget) was signed into law. As a result, Section 12H.14. (c) of the Act repealed N.C. General Statute §108A-70.21(g), which authorized the purchase of Extended Coverage or buy-in for NC Health Choice beneficiaries who had become ineligible for insurance because of a family income increase. Due to the repeal of the Extended Coverage General Statute, effective October 1, 2015, the program was terminated.

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

Guidance: States have the option to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1) “lawfully residing” children described at section 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

4.1- LR

Lawfully Residing Option (Sections 2107(e)(1)(J) and 1903(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes: SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

26 (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. §1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Elected for pregnant women. Elected for children under age 19

4.1.1-LR The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, it has verified, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

4.1-DS

Supplemental Dental (Section 2103(c)(5) - A child who is eligible to enroll in dental-only SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

27 supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low- income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

4.2. Assurances The State assures by checking the box below that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1. These standards do not discriminate on the basis of diagnosis.

4.2.2. Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income. This applies to pregnant women included

in the State plan as well as targeted low-income children.

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

medical condition. This applies to pregnant women as well as targeted low-

income children.

4.2-DS Supplemental Dental - Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1-DS These standards do not discriminate on the basis of diagnosis.

4.2.2-DS Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income.

4.2.3-DS These standards do not deny eligibility based on a child having a pre-

existing medical condition.

4.3. Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section 2102)(b)(2)) (42 CFR 457.350)

A. Application Availability: Joint application forms for Medicaid and NC Health Choice for Children are available at community government offices including local health departments, county DSS offices, and unemployment offices. Special displays and application forms are also available at community locations frequented SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

28 by potential applicants. These include: Human Resource departments of local employers; public school administration and school nurse areas; neighborhood churches; non-profit food distribution centers; subsidized and church-based day care; and Mother’s Day Out locations. In addition, outreach workers regularly visit and maintain outstations within safety net hospital Emergency Departments, Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC), migrant health centers, and Indian health centers.

English and Spanish versions of application forms and educational materials are available for on-line completion and printing from the NC DHHS Health Choice Program Web pages. Assistance in filling out the forms is available through county DSS and any of the specially designated outstations.

Eligibility Determination: NC Health Choice provides 12 months of continuous coverage for eligible children. The 12-month certification period for siblings within the same household can differ if the siblings apply for and are approved for coverage in different months.

All new and renewal applications are processed within the CMS standard of 45 calendar days from the received date of the signed application. The receipt date (Processing Day One) is the calendar day on which the county social services office receives the signed application. Mail picked up from the post office for processing on a non-State business day is determined as officially received on the next State business day. Applicants may apply via telephone with a DSS and the date of the application will be the call date. However, applicants must follow up with a signature page within the application processing time frame. Any unsigned application is not a valid application and does not preserve the potential effective date even if the child is ultimately approved for coverage.

CHIP Disaster Relief: • At the State’s discretion, the State will extend the redetermination timelines for current CHIP enrollees living and/or working in Governor declared or federally declared disaster areas or other areas as determined by the North Carolina Department of Health and Human Services. (42 CFR 457.340)

Enrollment Fee: Counties collect an annual enrollment fee when family income is between 159% and 211% of FPL. The annual fee is $50 per child, with a $100 maximum per family for two or more children. The county DSS retains each enrollment fee to help offset application processing administrative costs. Applicants who are members of a federally recognized American Indian tribe and Alaskan Natives are exempt from the enrollment fee and are identified by a unique race code and enrollment category.

CHIP Disaster Relief: • The State may also waive: (1) the annual enrollment fee and co-payments; and (2) unpaid enrollment fee balances for applicants and/or current enrollees who are living and/or working in Governor declared or federally declared disaster areas or other areas as SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

29 determined by the North Carolina Department of Health and Human Services.

Enrollment Method: County DSS caseworkers enter new enrollments into NC FAST, a statewide eligibility information system. NC FAST also generates an automated Notice of Eligibility or denial of approval for benefits for each applicant. The notice is mailed to the applicant within one (1) business day of the decision.

Once an applicant is deemed eligible, coverage is retroactively effective as of the first day of the month in which the applicant submitted a signed application. There are, however, two exceptions to the availability of a retroactive effective date since Health Choice beneficiaries cannot have any other form of comprehensive health insurance: 1. If the child has active Medicaid in the month of a Health Choice application, NC Health Choice coverage begins the first day of the month following Medicaid termination. 2. If the child has active comprehensive insurance in the month of application, NC Health Choice coverage begins the first day of the month following other insurance termination. The State requires written proof of the other insurance termination date and cannot accept verbal confirmation from the applicant.

New Enrollments: The experience of the typical enrollee will be as follows: The family learns about the NC Health Choice program, completes the joint Medicaid – Health Choice application form online on the Federally Facilitated Marketplace, via mail, or in person at the county DSS. The local DSS assesses the application and makes one of three possible determinations within 45 days: 1. The child is eligible for Medicaid The caseworker enters application and enrollment information into NC FAST, including the Medicaid coverage effective date.

2. The child is eligible for NC Health Choice The caseworker enters application and enrollment information into NC FAST with three possible outcomes:

a. No Annual Enrollment Fee Required: The caseworker creates the new enrollment with the coverage effective date in NC FAST. b. Annual Enrollment Fee Required: The annual enrollment fee must be paid in full prior to enrollment and coverage activation for eligible children in a family with an annual income level requiring the fee. The child is enrolled in the Title XXI program after receipt of the appropriate enrollment fee for families between 159-211% FPL. American Indian and Alaskan Native children are exempt from this requirement regardless of family income. SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

30

The enrollment fee is $50 for one child and $100 for two or more children in the same family. The family has twelve (12) calendar days from the date on the county DSS Notice of Eligibility to pay the enrollment fee. During the initial 12-day period, applicants may ask for an additional twelve (12) days to pay the enrollment fee. If the fee remains unpaid as of the 13th calendar day of the extension period DSS will mail a denial / termination notice to the applicant.

c. Enrollment Freeze The child is eligible for NC Health Choice. However, he or she cannot be enrolled because the State’s NC Health Choice budget is insufficient to cover additional enrollees (Title XXI is not an entitlement program). New eligible applications are frozen and the child’s name is added to the statewide “wait list.” The enrollment fee (if required) is not billed or requested until an enrollment opening becomes available for the child. Section 4.3.1 contains additional information about the Enrollment Freeze policy and procedures.

3. Applicant is Ineligible for both Medicaid and NC Health Choice The child fails to meet one or more eligibility requirements for both programs and is ineligible for both Medicaid and NC Health Choice.

B. Renewal Review/ Enrollment: NC Health Choice provides 12 months of continuous enrollment without regard to changes in income. An increase in family income during the enrollment period has no impact on NC Health Choice eligibility, even if the new household income is above 211% FPL. Enrollees are not required to notify the DSS or tribal caseworker regarding income changes during the continuous enrollment period. If the family notifies the caseworker of increased household income, the file will be annotated and reviewed at renewal through current income verification requirements.

A decrease in family income below the NC Health Choice minimum income requirement also does not affect eligibility during the continuous enrollment period. However, a parent or guardian may request an eligibility re-evaluation to determine Medicaid eligibility. Upon Medicaid approval, NCHC coverage is terminated and Medicaid enrollment created with no gap in coverage.

North Carolina DSS offices implement an ex parte process to facilitate re-enrollment for CHIP beneficiaries. If an enrollment fee is due, the family has 12 calendar days from the date on the county DSS or tribal Notice of Enrollment Fee to pay the fee. If the fee remains unpaid as of the 13th calendar day following the notice date, the case is terminated for non-payment of the enrollment fee.

SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

31 Guidance: The box below should be checked as related to children and pregnant women. Please note: A State providing dental-only supplemental coverage may not have a waiting list or limit eligibility in any way.

4.3.1. Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(2)) (42 CFR 457.305(b))

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

The North Carolina DHHS Secretary may choose to freeze new NC Health Choice enrollments if State- appropriated funds are depleted prior to the end of the State fiscal year. This process is referred to as a “freeze.” Current beneficiaries who remain eligible at renewal receive another 12-month continuous eligibility period; however newly eligible applicants are placed on a waiting list. The State notifies CMS prior to initiation of an enrollment freeze and associated wait list. The general public, potential beneficiaries, and enrolled children receive notification through public media (newspaper and website) of the new enrollment suspension and wait list process.

The freeze remains in place indefinitely until the NC DHHS Secretary determines that enrollment levels are within budgeted and legislated parameters. However, a freeze period can be no less than two consecutive months. The chart below identifies Enrollment Freeze Notice Requirements.

# Days Prior to Freeze Effective Date: Contact Notification Method 45 calendar days US DHHS CMS Phone call to CMS Regional Coordinator Written notice to same 60 calendar days Current Enrollees

Written notice to currently enrolled beneficiaries NC DHHS website alert

30 calendar days Public – Providers DMA NC Medicaid Provider Bulletin Recorded notice on Automated Verification Response System (AVRS) Posted notice on web-based eligibility system, NC FAST

SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

32

# Days Prior to Freeze Effective Date: Contact Notification Method 30 calendar days Public – DSS Offices “Dear County Director” notification letter Notice of enrollment freeze posted on DSS intranet.

30 calendar days Public Outreach Groups Other State Agencies NCHC Contractors

Notification Letter to existing advocacy, outreach, and key stakeholder entities Mass internal email notice to all state agency management personnel 20 calendar days Media NC DHHS Press Release

Notice will be provided to the Centers for Medicaid and Medicare Services (CMS) 45 days in advance of the implementation of any enrollment freeze. Written notification will be announced to the current enrollees via letter 60 days prior to the imposition of an enrollment freeze and to the news media no later than 20 days before a new enrollment freeze is to be implemented. The purpose of the plan is two-fold: • Limit enrollment in a manner that does not impose an extra burden on families to file multiple repeat applications; and • Allow children to enroll as slots become available rather than waiting for a pre-established date. The initial closure will last a minimum of two consecutive months to allow children with renewals in the first month of the freeze period adequate time to submit their renewal application, including the grace period, and to begin to build an inventory of open enrollment slots. New Application Processing: The NC Health Choice freeze has no impact on the Medicaid program. Medicaid is an entitlement program in which the State enrolls all qualified beneficiaries. As a Title XXI program, NC Health Choice is not an entitlement program. Enrollment is dependent upon available State funding to cover plan medical and administrative expenses for current enrollees in addition to new applicants. However, families may continue to file applications and counties will determine eligibility as usual. In addition, Medicaid is always evaluated first before applying the NC Health Choice freeze

Medicaid Eligible: Children determined eligible for Medicaid will be approved and enrolled.

• NC Health Choice Eligible (during new enrollment freeze) Children determined newly eligible for NC Health Choice will be denied enrollment and provided with information that the child qualifies for the program, yet cannot be enrolled due to a freeze. The child will SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

33 be added to the statewide wait list for later notification by the DSS caseworker when a new enrollment slot becomes available or the freeze is lifted. The State establishes an automated wait list within NC FAST and adds the child to the end of the waiting list. Children eligible for NC Health Choice on the inactive wait list are not included in the nightly updates sent to the Claims Processing Contractor until they are enrolled in an available program slot or the new enrollment freeze is lifted.

• Ineligible for Medicaid and NC Health Choice If the child is determined to be ineligible for either program, the application will be denied with no further action. However, the family may choose to re-apply at any time.

Renewal Enrollments: Children currently enrolled in NC Health Choice receive a new 12-month continuous eligibility period with no break in coverage if the signed renewal application is received within the ten-day grace period. The signed application must be received by the county DSS office within ten (10) calendar days of the renewal date. An unsigned application is not a valid application and does not preserve the renewal enrollment exception permitted during the freeze. Renewal applications received by the county DSS after the ten-day grace period are handled as new applications and processed accordingly.

New Application Wait List Procedures: • At the time of application, a registration number is created so the wait list applications can be sequenced chronologically according to the date of application stored in NC FAST. • The State reactivates applications on a first in – first out method based on the registration number. When a child’s application is re-activated for enrollment, the child is removed from the waiting list and the number of NC Health Choice children on the application reduces available enrollment slots. • When the NC DHHS Department of Medical Assistance (DMA) determines that there are available program openings to allow for new enrollments, it will notify the Division of Information Resources Management (DIRM) of the specific number of open slots. The notification can occur during the freeze if it is determined enough children have dropped off of NC Health Choice (due to ineligibility or becoming eligible for Medicaid. The waiting list can be reduced in increments as determined by DMA Management until the freeze is lifted. The waiting list is reduced in date order. • The 45-calendar day application processing timeline begins the day the case is re-activated. NC FAST generates notification to the family that the application has been re-opened and asks that the family confirm their current residence address and the child’s current insurance status. The family has 12 calendar days to provide the requested information. Day One is the date of re-activation notice issuance as recorded in the NC FAST case history data. • If the family does not return the reactivation notice within 12 calendar days from the letter production date, the county caseworker checks agency records to see whether an address change has occurred and will mail a second notice. The family has 12 calendar days from the date of the EIS re-activation notice to respond to the 2nd request for current information. • Incomplete or unsigned information forms received by the DSS or result in a new letter to the family requesting the missing information. The family has 12 calendar days from the date of the letter to SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

34 respond. A 2nd letter is sent on the 13th calendar day and gives the family another 12 calendar days to respond. • The application is denied on the 46th calendar day after reactivation if there is no response or it remains incomplete. The county DSS takes no action on the re-activated application pending return of the completed and signed information update. Should a family not reply within 45 days, the application is denied and the number of enrollment positions allotted for the children in the family are released to the children next in line on the wait list. The family has the right to submit a new application at any time, and is subject to all new application requirements and/or restrictions in place at that time. • If required information is completed and the child remains eligible and approved for NC Health Choice, the caseworker mails a notice within 45 days of the decision. The notice includes the amount of any enrollment fee due with the statement that full payment is required prior to the child’s enrollment and NC Health Choice coverage activation. • NC Health Choice benefits begin the first day of the application re-activation month and will continue for 12 consecutive months from that date.

Ending the Enrollment Freeze If the State budget shortfall and enrollment cap are resolved, all children on the wait list receive enrollment review priority. Wait list children must have the first opportunity to enroll in the program before enrollment opens to new applicants in general. The NC DHHS immediately notifies CMS in writing of the freeze end date and the number of children on the wait list. Wait listed applications will be reviewed in chronological order based on the date that they were added to the wait list. If an application on the wait list is re-activated within three months (90 calendar days) of the date the child was initially placed on the wait list, the family must confirm the child’s current insurance status. The State will use the verified income from when the applicant first applied to determine eligibility. If an applicant is on the wait list for longer than three months, caseworkers will re-verify insurance and income at the time of re-activation.

Based upon family income, some children must pay annual enrollment fees in order to re-enroll. Children who have applied and been determined eligible for NC Health Choice with an enrollment fee requirement do not pay the enrollment fee until they are off of the waiting list and ready to enroll in the program. However, if the required annual enrollment fee is not paid, the wait listed applicant will be denied re- enrollment.

Guidance: Note that for purposes of presumptive eligibility, States do not need to verify the

citizenship status of the child. States electing this option should indicate so in the

State plan. (42 CFR 457.355)

4.3.2. Check if the State elects to provide presumptive eligibility for children that meets the requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR 457.355)

Guidance: Describe how the State intends to implement the Express Lane option. Include information on the identified Express Lane agency or agencies, and whether the SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

35 State will be using the Express Lane eligibility option for the initial eligibility determinations, redeterminations, or both.

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

4.3.3.1-EL Also indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

4.3.3.2-EL List the public agencies approved by the State as Express Lane agencies.

4.3.3.3-EL List the components/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option.

4.3.3.3-EL List the component/components of CHIP eligibility that are determined under the Express Lane.

4.3.3.4-EL Describe the option used to satisfy the screen and enrollment requirements before a child may be enrolled under title XXI.

Guidance: States should describe the process they use to screen and enroll children required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe the screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by an Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated. Describe whether the State is temporarily enrolling children in CHIP, based on the income finding from an Express Lane agency, pending the completion of the screen and enroll process.

In this section, states should describe their eligibility screening process in a way that SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

36 addresses the five assurances specified below. The State should consider including important definitions, the relationship with affected Federal, State and local agencies, and other applicable criteria that will describe the State’s ability to make assurances. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)), (42 CFR 457.310(b)(2), 42 CFR 457.350(a)(1) and 457.80(c)(3))

4.4. Eligibility screening and coordination with other health coverage programs States must describe how they will assure that:

4.4.1. only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance (including access to a State health benefits plan) are furnished child health assistance under the plan. (Sections 2102(b)(3)(A), 2110(b)(2)(B)) (42 CFR 457.310(b), 42 CFR 457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women.

Pursuant to N.C. GEN. STAT. § 108A 70.21(a)(1), an applicant is ineligible for the NC Health Choice program if he or she is insured or is eligible for Medicaid, Medicare, or other federal government sponsored insurance. A child must be uninsured to be eligible for NC Health Choice. Uninsured means the applicant is not covered under any private or employer- sponsored creditable health insurance plan on the date of enrollment into the program and is ineligible for Medicaid, Medicare or other federal government sponsored insurance.

4.4.2. children found through the screening process to be potentially eligible for medical assistance under the State Medicaid plan are enrolled for assistance under such plan; (Section 2102(b)(3)(B)) (42 CFR 457.350(a)(2)).

Medicaid and NC Health Choice use the same application form to ease the administrative burden on families applying for benefits. County caseworkers initially screen all applications for Medicaid eligibility. If the child is not eligible for Medicaid, the review progresses with an evaluation of NC Health Choice eligibility. The review includes a search of the NC FAST database for existing Title XIX or Title XXI enrollment or the presence of other creditable insurance. Citizenship and identity status for each applicant is validated through automated queries and responses between the SS Bendex database and the DSS county office or tribal office. DSS workers obtain income verification, and request any additional information necessary. If family income is within Title XIX limits and the child meets all other Medicaid eligibility requirements, Medicaid enrollment occurs.

4.4.3. children found through the screening process to be ineligible for Medicaid are enrolled in CHIP. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4)) During the application process described in 4.4.2 above, if family income exceeds the Medicaid income limit and is at or below 211% of FPL, the child will be enrolled in the NC Health Choice Program if all other Program eligibility requirements set forth in G.S. 108A-70.21(a) are met. SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

37

4.4.4. the insurance provided under the State child health plan does not substitute for coverage under group health plans. (Section 2102(b)(3)(C)) (42 CFR, 457.805)

A child must be uninsured to be eligible for NC Health Choice. As defined in G.S. 108A-70.18(8), “uninsured” means the applicant is not covered under any private or employer-sponsored comprehensive health insurance plan on the date of enrollment. Comprehensive coverage is health insurance that provides basic medical care and hospitalization, whether group, private plan, HMO, or other managed care plan. It also includes Medicare, TRICARE, State health insurance risk pools and other public health plans. Comprehensive insurance does not include policies that pay for specific illnesses or pay a daily amount while a person is hospitalized.

A child is also considered uninsured if: ● The non-custodial parent with a court order for medical support is providing coverage through a medical insurance plan (e.g., a managed care plan with a limited network of providers) that is located outside of the child's state of residence. ● The non-custodial parent with a court order for medical support is not providing coverage under a medical insurance policy even if he or she has been ordered to make direct payment for medical care. ● He or she is covered by a full service Health Maintenance Organization (HMO) which does not have a network of medical providers in the child’s county of residence (and therefore the child does not have “reasonable geographic access to care” pursuant to 42. C.F.R. § 457.310(b)(2)(ii).

State employees must pay 100% of the monthly health insurance premium costs for any dependents covered under the State Employees’ health insurance plan. There is no “more than nominal” amount contributed by the State. Therefore, pursuant to 42 C.F.R. § 457.310(c)(1), children of State employees and teachers are eligible for coverage under Title XXI in North Carolina.

If an otherwise eligible child has active comprehensive health insurance as of the date of application, NC Health Choice enrollment will begin on the first day of the month following proof of a termination date for other coverage. Beneficiaries enrolled following voluntarily termination of private or employer-sponsored comprehensive health insurance are assigned a specific enrollment code to permit the State to determine whether the crowd out rate is negatively impacted.

4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premium assistance program, describe: 1) the minimum period without coverage under a group health plan. This should include any allowable exceptions to the waiting period; 2) the expected minimum level of contribution employers will make; and 3) how cost-effectiveness is determined. (42 CFR 457.810(a)-(c))

4.4.5. Child health assistance is provided to targeted low-income children in the State who are American Indian and Alaska Native. (Section 2102(b)(3)(D)) (42 CFR 457.125(a)) SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

38 American Indian and Alaska Native children who self-identify at the time of application are exempt from all enrollment fees and co-payments associated with the Program. Eligibility categories and cost-sharing requirements are outlined in Section 8.

American Indian and Alaska Native beneficiaries in the NC Health Choice Program are also subject to other exceptions pursuant to federal regulations. For example, these beneficiaries are eligible for the federal Vaccines for Children Program, and the Division of Medical Assistance notifies providers that they are to administer vaccines accordingly. All other beneficiaries in North Carolina’s separate CHIP Program are deemed “insured” and therefore ineligible for the Vaccines for Children Program. For American Indian and Alaska Native beneficiaries, the assignment of a primary care provider medical home within the Community Care of North Carolina (CCNC) primary care case management delivery system is optional; the assignment is mandatory for all other NC Health Choice Program beneficiaries.

Guidance: When the State is using an income finding from an Express Lane agency, the State must still comply with screen and enroll requirements before enrolling children in CHIP. The State may either continue its current screen and enroll process, or elect one of two new options to fulfill these requirements.

4.4-EL The State should designate the option it will be using to carry out screen and enroll

requirements:

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 42 CFR 457.80(c). Describe this process.

The State is establishing a screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by the Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process.

Section 5. Outreach and Coordination

SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

39 5.1. (formerly 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2. (Section 2102)(a)(2) (42 CFR 457.80(b))

Guidance: The information below may include whether the state elects express lane eligibility a description of the State’s outreach efforts through Medicaid and state-only programs.

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

North Carolina employs a combined marketing approach for the State Title XIX and XXI Programs. Outreach approaches employ social marketing principles and consider the needs of diverse populations (e.g., preferred languages, ethnic and cultural social norms, the specific concerns for parents/guardians of children with special health care needs, and materials targeted for low literacy populations). The Division of Public Health in the NC Department of Health and Human Services has a staff position focusing specifically on minority outreach for Health Check (Medicaid for Children) and NC Health Choice. Establishing trust within the minority communities opens new doors for outreach and education. The DPH Minority Outreach Consultant works through minority-led State and Community-Based Organizations (CBOs) to reach African American, American Indian, Latino, and other Immigrant/Refugee communities. Education is carried out in venues such as mobile consulate visits, Latino heritage festivals, Hmong cultural celebrations, American Indian pow wows and the Commission on Indian Affairs, African American sororities/fraternities, and other social/cultural events. Minority-owned businesses (e.g., grocery stores, beauty salons, media, and restaurants) are often willing to share child health insurance information with their customers. Another outreach opportunity has been through faith-based services and family events within the Catholic (Latino, Vietnamese, and Congolese), Baptist (Korean) and Muslim (Arabic) traditions. Through the statewide Refugee Advisory Council, these relationships enable the State to focus- test professionally translated outreach materials in seven languages. The Refugee Advisory Council also keeps DMA abreast of the most rapidly growing refugee populations (currently Burmese, Bhutanese/Nepali, Vietnamese, Iraqi, Cuban and Somalian).

The NC Division of Public Health (DPH) leads outreach and marketing efforts in collaboration with a host of State, regional and local public and private partners. DPH publishes a one-page, bi-lingual (English and Spanish) fact sheet as part of its marketing efforts. Hard copies are mailed out with other consumer information about federal poverty guidelines, and DPH maintains electronic copies of the fact sheet on its Women’s and Children’s Health Web page. The Division of Medical Assistance also provides links to the electronic version of the fact sheet on its website. The fact sheet highlights income eligibility guidelines, health benefits available, and how to apply for both Medicaid and NC Health Choice.

Guidance: The State may address the coordination between the public-private outreach and the public health programs that is occurring statewide. This section will provide a historic record of the steps the State is taking to identify and enroll all uninsured SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

40 children from the time the State’s plan was initially approved. States do not have to rewrite his section but may instead update this section as appropriate.

5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in health insurance programs that involve a public- private partnership:

As the Title XXI program has matured since its inception in 1998, NC has re-focused outreach efforts on infrastructure development by working with partners to integrate outreach for child health insurance programs into the ongoing work of their State and local organizations. State and local partners engaged in child health insurance outreach include:

Early Childhood Organizations: Smart Start, More-at-Four, Head Start & Pre-Kindergarten Programs; Child Care Resource and Referral Agencies; Child Care Health Consultants; NC Association for the Education of Young Children; NC Division of Child Development; and various Child Care Provider Associations are all invaluable partners. The preschool age programs in particular educate parents before their children reach the Health Choice eligibility age of six years.

Schools: The NC Department of Public Instruction (DPI) collaborates through its NC Healthy Schools and Child Nutrition Sections (Free/Reduced Price School Meals). Other related collaborators include the School Nurses Association of North Carolina; the School Health Advisory Councils; the School Support Services Staff (Psychologists, Social Workers, Counselors); Coaches; School-Based and School Linked Health Centers; and the NC Parent Teacher’s Association. The NC Community Colleges’ Basic Skills and Literacy staff have also been partners in assisting with outreach efforts with their GED, Adult High School, and English-as-a-Second-Language classrooms (faculty and students).

Health Care Providers: Collaborators include the NC Pediatric Society; the NC Academy of Family Physicians; Local Medical Societies; Associations representing Physician Assistants and Nurse Practitioners; Safety Net Providers (Health Departments; Community, Rural, Indian and Migrant Health Centers; Free Clinics); the NC Hospital Association; and Hospital Finance and Emergency Department Staff.

Governmental Partners: Several Department of Health and Human Services divisions (Social Services, Medical Assistance, and Public Health) partner through their respective programs. Other governmental partners include the NC Office of Minority Health and Health Disparities; the Department of Public Instruction; the Employment Security Commission; the Department of Juvenile Justice and Delinquency Prevention; the Housing Authority; NC Community College System; Cooperative Extension Agencies; Parks and Recreation Departments; Vocational Rehabilitation agencies; the NC Commission of Indian Affairs; the Refugee Health Program; and the Division of Motor Vehicles. Pursuant to G.S. 143-682, a nine-member Commission appointed by the Governor is charged with monitoring and evaluating the provision of services to Children with Special Health Care Needs.

SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

41 Private Not-for-Profits: These collaborators include Community Action Agencies; Domestic Violence Shelters; United Way / 2-1-1; Homeless Shelters; Food Banks; Advocacy Groups; Communities in Schools; Legal Services; Libraries; Faith-Based Organizations; and the Salvation Army.

Businesses: Collaborators include the NC Association of Health Insurance Underwriters; the NC Hotel / Motel Association; Community College Small Business Centers; Banks; Local Chambers of Commerce, including the NC Hispanic and Black Chambers of Commerce; and Tax Preparers—particularly VITA centers across the State.

Media: The DPH consultant partners with minority media outlets whenever possible, including an annual appearance on the Univision talk show.

The focus of statewide activities is ultimately on local efforts through all of DMA’s partners, including Community Care of North Carolina (CCNC). Fourteen CCNC networks coordinate DMA Health Check Coordinators (HCCs). HCCs are available to assist parents and providers. The HCCs promote initial enrollment in Title XIX and XXI services, retention in the health insurance programs, access to a quality medical home, and the importance of preventive services and appropriate service utilization. Because the NC Health Choice Program has limited State appropriations for medical and administrative costs, it is critical to educate NC Health Choice members’ parents to use the health care system in the most appropriate way to keep their children healthy. The Program undertakes ongoing efforts to identify children with asthma, diabetes, behavioral-mental health, and other chronic diagnoses. The goal is to assure that children with chronic conditions are receiving all of the help they need to prevent emergency episodes. A major focus is medical management with the goal of providing health information and case management services for families with frequent visits or high cost episodes.

Guidance: The State should describe below how it’s Title XXI program will closely coordinate the enrollment with Medicaid because under Title XXI, children identified as Medicaid-eligible are required to be enrolled in Medicaid. Specific information related to Medicaid screen and enroll procedures is requested in Section 4.4. (42 CFR 457.80(c))

5.2. (formerly 2.3) Describe how CHIP coordinates with other public and private health insurance programs, other sources of health benefits coverage for children, other relevant child health programs, (such as title V), that provide health care services for low-income children to increase the number of children with creditable health coverage. (Section 2102(a)(3), 2102(b)(3)(E) and 2102(c)(2)) (42 CFR 457.80(c)). This item requires a brief overview of how Title XXI efforts – particularly new enrollment outreach efforts – will be coordinated with and improve upon existing State efforts described in Section 5.2.

The Division of Medical Assistance (DMA) in the NC Department of Health and Human Services has overall responsibility for the administration of Title XIX and XXI and assists outreach partners, providers and other stakeholders involved in seeking, identifying and enrolling uninsured children by providing county-level data. DMA also provides oversight of the eligibility determination and enrollment process implemented by local Departments of Social Services. The NC Health Choice Program works with the SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

42 Division of Public Health to increase general public awareness and targets special populations (low income, minority, and children with special health care needs) to assure that they know about both of the State’s publicly-funded child health insurance programs.

Applicants for both Medicaid and NC Health Choice complete a joint application online via the Federally Facilitated Marketplace, in person at a county Department of Social Services or via U.S. Mail. Applicants are screened first for Title XIX eligibility, and then for Title XXI eligibility. The “assets test” is not applicable to the NC Health Choice Program; children qualify for 12 months of continuous eligibility without regard to changes in family income during the enrollment period. To assist with renewal retention, the State mails ex parte renewal applications during the 10th month of continuous enrollment with a cover letter that advises beneficiaries to notify case workers if anything material that would affect program eligibility (such as health insurance status in the case of NC Health Choice) has changed. Otherwise, the beneficiaries do not have to return the form and renewal is automatic for an additional 12 consecutive months.

The efficient application process provides a number of program benefits: • It assures that children who are eligible for either Title XIX or Title XXI are enrolled in the most appropriate program based on the applicant’s eligibility; • It provides one standardized and consolidated source of enrollment data, which can be analyzed for the purpose of further refining outreach efforts; and • It avoids duplicative eligibility and enrollment infrastructures for the Title XIX and Title XXI programs.

5.2-EL The State should include a description of its election of the Express Lane eligibility option to provide a simplified eligibility determination process and expedited enrollment of eligible children into Medicaid or CHIP.

5.3. Strategies

Guidance:Describe the procedures used by the State to accomplish outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90) The description should include information on how the State will inform the target of the availability of the programs, including American Indians and Alaska Natives, and assist them in enrolling in the appropriate program.

Outreach strategies may include, but are not limited to, community outreach workers, outstationed eligibility workers, translation and transportation services, assistance with enrollment forms, case management and other targeting activities to inform families of low- income children of the availability of the health insurance program under the plan or other private or public health coverage. SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

43

Outreach efforts include all uninsured low-income North Carolina children potentially eligible for Title XIX or Title XXI coverage. Tribal organizations collaborate with State and local outreach staff to assist with educating tribal members about the North Carolina Medicaid and NC Health Choice programs. Education includes how to apply, eligibility criteria, covered benefits, how to access healthcare services, and appropriate use of the Emergency Room. Representatives from the NC Commission of Indian Affairs, will craft best practice strategies to reach the State’s American Indian communities and assure that all families with potentially eligible children are contacted and informed about this program and the health care benefits available to low-income children.

The North Carolina Division of Public Health runs a State-supported toll-free specialized resource line focused specifically on the needs, questions, benefits, and resources available to families of children with special needs in both the Health Check and NC Health Choice programs. The helpline provides telephone assistance for families with children with special needs and providers regarding health insurance and healthcare needs. The toll-free number is available to callers from 8 a.m. until 5 p.m. Monday through Friday at 1-800-737-3028. Additional outreach to families of children with special health care needs is done via health care providers and community-based organizations; NC Children’s Developmental Services Agencies; Family Support Networks; the Exceptional Children’s Assistance Center; and various diagnosis-specific groups such as the United Cerebral Palsy Association and the NC Autism Society.

A claims analysis for the 2014 State Fiscal Year revealed that out of the 20,016 NC Health Choice claims for Emergency Department visits, the top three reasons for the visits were: 1) asthma; 2) long-term use of medication; and 3) fever. In an effort to promote the most appropriate utilization of primary care and emergency room care, the NC Health Choice Program implements targeted efforts to promote wellness and disease management strategies. Related outreach materials have been developed in both English and Spanish.

Section 6. Coverage Requirements for Children’s Health Insurance

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan and proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT.

6.1. The State elects to provide the following forms of coverage to children: (Check all that apply.) (Section 2103(c)); (42 CFR 457.410(a))

Guidance: Benchmark coverage is substantially equal to the benefits coverage in a benchmark benefit package (FEHBP-equivalent coverage, State employee coverage, and/or the HMO coverage plan that has the largest insured commercial, non-Medicaid enrollment in the state). If box below is checked, either 6.1.1.1., 6.1.1.2., or 6.1.1.3. must also be checked. (Section 2103(a)(1))

SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

44 6.1.1.

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

Guidance: Check box below if the benchmark benefit package to be offered by the State is the standard Blue Cross/Blue Shield preferred provider option service benefit plan, as described in and offered under Section 8903(1) of Title 5, United States Code. (Section 2103(b)(1) (42 CFR 457.420(b))

6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1) (42 CFR 457.420(a)) (If checked, attach copy of the plan.)

Guidance: Check box below if the benchmark benefit package to be offered by the State is State employee coverage, meaning a coverage plan that is offered and generally available to State employees in the state. (Section 2103(b)(2))

6.1.1.2.

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

Guidance: Check box below if the benchmark benefit package to be offered by the State is offered by a health maintenance organization (as defined in Section 2791(b)(3) of the Public Health Services Act) and has the largest insured commercial, non-Medicaid enrollment of covered lives of such coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42 CFR 457.420(c)))

6.1.1.3.

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

Guidance: States choosing Benchmark-equivalent coverage must check the box below and ensure that the coverage meets the following requirements: ▪ the coverage includes benefits for items and services within each of the categories of basic services described in 42 CFR 457.430: • dental services • inpatient and outpatient hospital services, • physicians’ services, • surgical and medical services, • laboratory and x-ray services, • well-baby and well-child care, including age-appropriate immunizations, and • emergency services; ▪ the coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages (FEHBP-equivalent coverage, State employee coverage, or coverage offered through an HMO coverage plan that has the SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

45 largest insured commercial enrollment in the state); and ▪ the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the additional categories in such package, if offered, as described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services.

If 6.1.2. is checked, a signed actuarial memorandum must be attached. The actuary who prepares the opinion must select and specify the standardized set and population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The State must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State results.

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

6.1.2.

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

Guidance: A State approved under the provision below, may modify its program from time to time so long as it continues to provide coverage at least equal to the lower of the actuarial value of the coverage under the program as of August 5, 1997, or one of the benchmark programs. If “existing comprehensive state-based coverage” is modified, an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997, or one of the benchmark plans must be attached. Also, the fiscal year 1996 State expenditures for “existing comprehensive state-based coverage” must be described in the space provided for all states. (Section SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

46 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of enactment. If existing comprehensive State-based coverage is modified, provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997 or one of the benchmark plans. Describe the fiscal year 1996 State expenditures for existing comprehensive state-based coverage.

Guidance: Secretary-approved coverage refers to any other health benefits coverage deemed appropriate and acceptable by the Secretary upon application by a state. (Section 2103(a)(4)) (42 CFR 457.250)

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450) Guidance: Section 1905(r) of the Act defines EPSDT to require coverage of (1) any medically necessary screening, and diagnostic services, including vision, hearing, and dental screening and diagnostic services, consistent with a periodicity schedule based on current and reasonable medical practice standards or the health needs of an individual child to determine if a suspected condition or illness exists; and (2) all services listed in section 1905(a) of the Act that are necessary to correct or ameliorate any defects and mental and physical illnesses or conditions discovered by the screening services, whether or not those services are covered under the Medicaid state plan. Section 1902(a)(43) of the Act requires that the State (1) provide and arrange for all necessary services, including supportive services, such as transportation, needed to receive medical care included within the scope of the EPSDT benefit and (2) inform eligible beneficiaries about the services available under the EPSDT benefit.

If the coverage provided does not meet all of the statutory requirements for EPSDT contained in sections 1902(a)(43) and 1905(r) of the Act, do not check this box.

6.1.4.1.

Coverage of all benefits that are provided to children that is the same as the benefits provided under the Medicaid State plan, including Early Periodic Screening, Diagnostic, and Treatment (EPSDT).

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver.

6.1.4.3.

Coverage that the State has extended to the entire Medicaid population. SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

47

Guidance: Check below if the coverage offered includes benchmark coverage, as specified in §457.420, plus additional coverage. Under this option, the State must clearly demonstrate that the coverage it provides includes the same coverage as the benchmark package, and also describes the services that are being added to the benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage.

6.1.4.5.

Coverage that is the same as defined by existing comprehensive state-based coverage applicable only in New York, Pennsylvania or Florida. (under 42 CFR 457.440)

Guidance: Check below if the State is purchasing coverage through a group health plan, and intends to demonstrate that the group health plan is substantially equivalent to or greater than coverage under one of the benchmark plans specified in 457.420, through the use of a benefit-by-benefit comparison of the coverage. Provide a sample of the comparison format that will be used. Under this option, if coverage for any benefit does not meet or exceed the coverage for that benefit under the benchmark, the State must provide an actuarial analysis as described in 457.431 to determine actuarial equivalence.

6.1.4.6.

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

Guidance: Check below if the State elects to provide a source of coverage that is not described above. Describe the coverage that will be offered, including any benefit limitations or exclusions.

6.1.4.7.

Other. (Describe)

The Division of Medical Assistance administers NC Health Choice benefits equivalent to those of the NC Medicaid Program, with four exceptions: 1. No services for long-term care; 2. No non-emergency medical transportation; 3. No EPSDT; and 4. Dental services on a restricted basis in accordance with the criteria adopted by the Department. SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

48 Session Law 2011-145 directed the Department of Health and Human Services to transition health benefit changes in the NC Health Choice Program to provide coverage equivalent to benefits provided for Medicaid beneficiaries, with the exceptions noted above.

In July 2013, the NC Health Choice Program transitioned the administration of medical and pharmacy claims to CSC, the third party administrator for the Medicaid program operated under Title XIX of the Social Security Act. NC Division of Medical Assistance administrators believe that this transition will be the most cost-effective approach to administration of the NC Health Choice program. Having the NC Health Choice program clinical coverage policies, prior approval processes, utilization review, and claims systems administration parallel the NC Medicaid Program processes will reduce the cost of running the program.

NC Health Choice Program administration will parallel Medicaid administration only to the extent allowable by Title XXI, the code of federal regulations, and State statutes. NC Health Choice beneficiaries will therefore continue to be subject to unique eligibility, cost sharing requirements, and review process rights.

Guidance: All forms of coverage that the State elects to provide to children in its plan must be checked. The State should also describe the scope, amount and duration of services covered under its plan, as well as any exclusions or limitations. States that choose to cover unborn children under the State plan should include a separate section 6.2 that specifies benefits for the unborn child population. (Section 2110(a)) (42 CFR, 457.490)

If the state elects to cover the new option of targeted low income pregnant women, but chooses to provide a different benefit package for these pregnant women under the CHIP plan, the state must include a separate section 6.2 describing the benefit package for pregnant women. (Section 2112)

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

6.2.1.

Inpatient services (Section 2110(a)(1))

• The NC Health Choice Program will not cover any long-term care services. See Section 8 for co-payment requirements associated with this benefit. Utilization review and prior authorization for services may be required. • The state may waive the prior authorization requirements for services listed in Section 6 of the CHIP state plan for enrollees who are living and/or working in Governor declared or federally declared disaster areas or other areas as determined by the North Carolina Department of Health and Human Services.

6.2.2.

Outpatient services (Section 2110(a)(2)) SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

49

See Section 8 for co-payment requirements associated with this benefit. Utilization review and prior authorization for services may be required.

6.2.3.

Physician services (Section 2110(a)(3))

6.2.4.

Surgical services (Section 2110(a)(4))

The NC Health Choice Program will cover medically necessary surgical services under inpatient and outpatient services covered in Sections 6.2.1 and 6.2.2.

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) NC Health Choice will not include Early and Periodic Screening, Detection, and Treatment (EPSDT) services. However, pursuant to 42 CFR § 457.410(b)(1), NC Health Choice will cover annual office visits for preventive services (well-child visits) for children ages 6 through 18 and age-appropriate immunizations in accordance with the recommendations of the Advisory Committee on Immunization Practices. Pursuant to 42 CFR § 457.520, NC Health Choice Program beneficiaries receive well-child visits and age-appropriate immunizations at no cost to their families (an exception to the co-payment requirements outlined in Section 8). The following are considered well-child care services: • Routine physical examinations as recommended and updated by the American Academy of Pediatrics (AAP) ‘‘Guidelines for Health Supervision III’’ and described in ‘‘Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents.’’; • Laboratory tests associated with well-child routine physical examinations; • Immunizations and related office visits as recommended and updated by the Advisory Committee on Immunization Practices (ACIP); and • Routine preventive and diagnostic dental services (such as oral examinations, prophylaxis and topical fluoride applications, sealants, and x-rays) as described in the most recent guidelines issued by the American Academy of Pediatric Dentistry (AAPD).

6.2.6.

Prescription drugs (Section 2110(a)(6))

The Department may establish authorizations, limitations, and reviews for specific drugs, drug classes, brands, or quantities in order to effectively manage the NC Health Choice pharmacy program. Prior authorization must be obtained from the NC Health Choice Pharmacy Benefit Management Coordinator or its authorized agent for any drug on the prior authorization list before reimbursement will be available. The NC Health Choice Preferred Drug List is identical to the Medicaid Program Preferred Drug List. There is no limit to the number of prescriptions covered. See Section 8 for co- payment requirements associated with this benefit.

6.2.7.

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

SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

50 The Department may establish authorizations, limitations, and reviews for specific drugs, drug classes, brands, or quantities. Prior authorization may be required based on criteria as published in the NC Division of Medical Assistance’s NC Health Choice Clinical Coverage Policies. See Section 8 for co- payment requirements associated with this benefit.

6.2.8.

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

Utilization review and prior authorization for services may be required.

6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

Family planning services and supplies are covered benefits. However, contraceptives that can be purchased without a prescription or do not require the services of a physician for fitting or insertion are not covered. In addition, Health Choice does not cover sterilizations; neither the Health Choice nor Medicaid Program covers sterilization reversals.

Prenatal care and childbirth are not covered benefits under the NC Health Choice Program. However, if an NC Health Choice beneficiary becomes pregnant, she will be enrolled in the NC Medicaid for Pregnant Women program if her income is less than 196% of the Federal Poverty Level (FPL). The Medicaid for Pregnant Women program provides: • prenatal care, delivery, and care 60 days postpartum; • Services to treat medical conditions which may complicate the pregnancy (some services require prior approval); • Childbirth classes; and • Family planning services.

6.2.10.

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

Utilization review and prior authorization for services may be required.

6.2.11.

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

Utilization review and prior authorization for services may be required.

6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) SPA Number: NC-17-0001-MHPA Approval Date: December 21, 2018 Effective Date: October 1, 2017

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6.2.13.

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

Guidance: Home and community based services may include supportive services such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home.

6.2.14.

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

Personal Care Services (PCS) are not a covered benefit in the NC Health Choice Program.

Home and community-based covered benefits for beneficiaries are:

Home Health: Skilled Nursing Specialized Therapies Home Health Aide Services Medical Supplies

Hospice: Physician Services

Nursing Services

Medical Social Services

Counseling Services

Hospice Aide and Homemaker Services

Volunteer Services

Medical Appliances and Supplies

Drugs and Biologicals

Therapy Services

Short-Term Inpatient Care

Ambulance Services

Nursing Facility and ICF/MR Room and Board