Department of Health & Human Services Centers for Medicare & Medicaid Services 61 Forsyth St., Suite 4T20 Atlanta, Georgia 30303-8909

February 9, 2010

Craigan Gray, MD, MBA, JD Director Division of Medical Assistance North Carolina Department of Health and Human Services 2501 Mail Service Center Raleigh, North Carolina 27699-2501

Attention: Teresa Smith

RE: North Carolina Title XIX State Plan Amendment, Transmittal #09-017

Dear Dr. Gray:

We have reviewed the proposed amendment to the North Carolina Medicaid State Plan that was submitted under transmittal number 09-017 and received in the Regional Office on September 29, 2009. This amendment adjusts State Fiscal Year (SFY) 2010 rates for Rehabilitation Services based on an overall program reduction of 4.68 percent for SFY 2010. SFY 2011 rates are to be frozen at the SFY 2010 amount.

Based on the information provided, we are pleased to inform you that Medicaid State Plan Amendment 09-017 was approved on February 4, 2010. The effective date of this amendment is July 1, 2009. We are enclosing the approved form HCFA-179 and plan pages.

If you have any questions or need any further assistance, please contact Clarence Lewis at (404) 562-7432, Cheryl Brimage at (404) 562-7116 or Rita Nimmons at (404) 562-7415.

Sincerely,

/s/

Mary Kaye Justis, RN, MBA

Acting Associate Regional Administrator

Division of Medicaid & Children's Health Operations Enclosures

Attachment 3.1-A.1 Page 7c.1

4.b(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services

Services provided under this section are provided by licensed practitioners (within their scope of practice as determined by the North Carolina Practice Acts per discipline) or programs/agencies for the mentally ill and substance abusers certified as meeting the program standards of the Commission on Mental Health, Developmental Disabilities and Substance Abuse Services or as Critical Access Behavioral Health Care Agencies, and directly enrolled by the Medicaid Staff of the agency providing services will also meet requirements set forth in Federal regulations or the requirements for one of the three categories described on pages 7c.10 and 7c.11. These services are available to categorically needy and medically needy recipients. Services include the following:

Medically necessary diagnostic evaluations or assessments (Diagnostic Assessment) identify the existence, nature and extent of illness. The services may include a systematic appraisal of mental, psychological, physical, behavioral, functional, social, economic and/or intellectual limitations and resources of the individual in order to determine the nature and extent of illness. This information will be used in the formulation of an individualized person centered plan for the recipient.

Other medically necessary diagnostic, screening, treatment, preventive and rehabilitative (ODSPR) services for the mentally ill and substance abusers are covered benefits when medically necessary. Screening services means the use of standardized tests given under medical direction. Diagnostic, preventive, or rehabilitative services must be ordered by a physician, licensed psychologist, physician’s assistant or nurse practitioner practicing within the scope of his/her practice according to Chapter 90 of the North Carolina General Statutes.

Covered services are provided to recipients in their residence or in a community setting, which may be any location other than in a public institution (IMD), other inpatient setting, jail or detention facility.

Inpatient psychiatric facilities serving individuals under age 21 will meet the requirement of 42 Code of Federal Regulations Part 441, Subpart D, and Part 483, Subpart G.

The following services will be covered when a determination is made that the services are medically necessary and will meet specific behavioral health needs of the recipient. Specific services must correct or ameliorate diagnosable conditions or prevent the anticipated deterioration of the patient’s condition. Services provided to family members of the recipient must be related to the recipient’s mental health/substance abuse disability.

Covered services for EPSDT children include but are not limited to: Evaluation/Assessments/Psycho-therapy/Behavioral Health Counseling, Diagnostic Assessment, Community Supports Child, Day Treatment, Partial Hospital, Mobile Crisis Management, Intensive In Home, Multisystemic Therapy, Substance Abuse Intensive Outpatient, and Ambulatory Detoxification.

TN No.: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No.: 05-005

Attachment 3.1-A.1 Page 7c.2

4.b.(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Description of Services

(a) Evaluation/Assessments/ Psycho-therapy/Behavioral Health Counseling For the complete description of the service, see Attachment 3.1-A.1 pages 7c.11 and 7c.12.

(b) Diagnostic Assessment (42 CFR 440.130(a)) This is a clinical face to face evaluation of a recipient’s MH/DD/SAS condition that will establish a need for the enhanced benefit package of services. It is a team service and must include evaluations by either, a physician, physician assistant, nurse practitioner or licensed psychologist who can sign an order for services and a licensed or certified practitioner with expertise in MH/DD/SAS as appropriate and consist of the following: • a chronological general health and behavioral health history (includes both mental health and substance abuse) of the recipient’s symptoms, treatment, treatment response and attitudes about treatment over time, emphasizing factors that have contributed to or inhibited previous recovery efforts; biological, psychological, familial, social, developmental and environmental dimensions and identified strengths and weaknesses in each area; • a description of the presenting problems, including source of distress, precipitating events, associated problems or symptoms, recent progressions, and current medications; • a strengths/problem summary which addresses risk of harm, functional status, co- morbidity, recovery environment, and treatment and recovery history; • diagnoses on all five (5) axes of DSM-IV; • evidence of an interdisciplinary team progress note that documents the team’s review and discussion of the assessment; • a recommendation regarding target population eligibility; and • evidence of recipient participation including families, or when applicable, guardians or other caregivers.

Documentation must include the following elements: • a chronological general health and behavioral health history (includes both mental health and substance abuse) of the recipient’s symptoms, treatment, treatment response and attitudes about treatment over time, emphasizing factors that have contributed to or inhibited previous recovery efforts; biological, psychological, familial, social, developmental and environmental dimensions and identified strengths and weaknesses in each area; • a description of the presenting problems, including source of distress, precipitating events, associated problems or symptoms, recent progressions, and current medications; • strengths/problem summary which addresses risk of harm, functional status, co- morbidity, recovery environment, and treatment and recovery history; • diagnoses on all five (5) axes of DSM-IV; • evidence of an interdisciplinary team progress note that documents the team’s review and discussion of the assessment; • a recommendation regarding target population eligibility; and • evidence of recipient participation including families, or when applicable, guardians or other caregivers. A recipient may receive one diagnostic assessment per year without any additional authorization. TN No.: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No.: 05-005

Attachment 3.1-A.1 Page 7c.3

4.b.(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Description of Services

(c ) Community Supports Child (CS) (CFR 42 440.130(d)) Community Support services are community-based rehabilitative services and interventions necessary to treat children and adolescents 20 years old or younger to achieve their mental health and/or substance abuse recovery goals and to assist parents and other caregivers in helping children and adolescents build resiliency. These medically necessary services directly address the recipient’s diagnostic and clinical needs, evidenced by the presence of a diagnosable mental, behavioral, and/or emotional disturbance (as defined by the DSM-IV-TR and its successors), with symptoms and effects documented in a comprehensive clinical assessment and a Person Centered Plan.

These services are designed to: • enhance skills necessary to address the complex mental health and/or substance abuse symptoms of children and adolescents who have significant functional deficits due to these disorders, to promote symptom reduction and improve functioning in their daily environments; • assist the child/adolescent and family in acquiring the necessary skills for reaching recovery from mental health and/or substance abuse disorders, for self management of symptoms and for addressing vocational, housing, and educational needs; • link recipients to, and coordinate, necessary services to promote clinical stability and meet the mental health/substance abuse treatment, social, and other treatment support needs while supporting the emotional and functional growth and development of the child; and • monitor and evaluate the effectiveness of delivery of all services and supports identified in the Person Centered Plan.

TN No: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No: 08-011

Attachment 3.1-A.1 Page 7c.3e

4.b.(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Description of Services

Paraprofessional (PP) within the MH/DD/SAS system of care means an individual who, with the exception of staff providing respite services or personal care services, has a GED or high school diploma; or no GED or high school diploma, employed prior to November 1, 2001 to provide a MH/DD/SAS service. Supervision shall be provided by a qualified professional with the population served. The supervisor and the employee shall develop an individualized supervision plan upon hiring. The parties shall review the plan annually.

TN No: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No: 08-011

Attachment 3.1-A.1 Page 7c.4

4.b.(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Description of Services

(d) Mental Health Day Treatment This service is available for children from age 3 up through age 20 and includes therapeutic or rehabilitation goals of the consumer in a structured setting. NOTE: Services for children from age 0 to age 3 can be found at Attachment 3.1-A.1 page 7g.1 “Early Intervention Rehabilitative Services.” This is an existing service which has been modified to increase provider qualifications, require additional training for providers and require prior authorization. The interventions are outlined in the child/adolescent person centered treatment plan and may include: • behavioral interventions, • social and other skill development, • communication enhancement, • problem- solving skills, • anger management, • monitoring of psychiatric symptoms; and • psycho-educational activities as appropriate.

These interventions are designed to support symptom stability, increase the recipient’s ability to cope and relate to others and enhancing the highest level of functioning possible. The service will also contain a care coordination component with assessment, monitoring, linking to services related to mental health needs and coordination of mental health serices. Documentation must include: a daily full service note that includes the recipient’s name, Medicaid identification number, date of service, purpose of contact, describes the provider’s interventions, includes the time spent performing the interventions, effectiveness of the intervention, and the signature of the staff providing the service. This service must be available three hours a day minimally in a licensed program. The provider agency must be certified and enrolled as a Critical Access Behavioral Health Care Agency by July 1, 2009. All services in the milieu are provided by a team which may have the following configuration; providers meet the qualified professional requirements, associate professionals and paraprofessionals. The service must be ordered by a physician, licensed psychologists, physician’s assistant or nurse practitioner and prior approval will be required via the statewide UR vendor or by an approved LME, contracted with the Medicaid Agency and meeting the same standards and requirements as the statewide vendor. This initial prior approval process will ensure that the level of the service is appropriate and concurrent reviews will determine the ongoing medical necessity for the service or the need to move up or down the continuum of services to another level of care. This service can only be provided by one day treatment provider at the time and cannot be billed on the same day as any inpatient, residential, or any other intensive in home service.

_____________________________________________________________________________________ TN No.: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No.: 05-005

Attachment 3.1-A.1 Page 7c.5

4.b.(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Description of Services

(e) Partial Hospital (PH) This is a short term service for acutely mentally ill children which provides a broad range of intensive therapeutic approaches which may include: • Individual/group therapies, • Increase the individual’s ability to relate to others, • Community living skills/training, • Coping skills, • Medical services; and • This is used as a step up to inpatient or a step down from inpatient.

Physician involvement is required. This service must be offered at a minimum of 4 hours per day, 5 days/week. Clinical criteria (medical necessity criteria for admission and continued stay) are embedded in the service definition. Documentation must include: a daily full service note that includes the recipient’s name, Medicaid identification number, date of service, purpose of contact, describes the provider’s interventions, includes the time spent performing the interventions, effectiveness of the intervention, and the signature of the staff providing the service. The service must be ordered by a physician, licensed psychologists, physician’s assistant or nurse practitioner and prior approval will be required via the statewide UR vendor or by an approved LME contracted with the Medicaid Agency and meeting the same standards and requirements as the statewide vendor. This initial prior approval process will ensure that the level of the service is appropriate and concurrent reviews will determine the ongoing medical necessity for the service or the need to move up or down the continuum of services to another level of care.

Provider agencies for Partial Hospitalization are licensed by the Division of Health Service Regulation, endorsed by the LMEs as meeting the program specific requirements for provision of Partial Hospitalization and enrolled in Medicaid. The staff providing this service are employees of the enrolled agency. Their qualifications and the discrete service components they perform are listed below.

All services in the Partial Hospital are provided by a team, which may have the following configuration: social workers, psychologists, therapists, case managers, or other MH/SA paraprofessional staff. The partial hospital milieu is directed under the supervision of a physician. Staff shall include at least one qualified mental health professional. The following sets forth the activities included in this service definition. These activities reflect the appropriate scope of practice for the Partial Hospital staff identified below.

Physician: Participate in diagnosis, treatment planning, and admission/discharge decisions. Social Workers, Psychologists, therapists: Group activities and therapy such as individual therapy and recreational therapy.

Case Managers: Case Management functions

Paraprofessional staff: Community living skills/training under the supervision of a Qualified Professional. TN No.: 09-017 Supersedes

Approval Date: 02-04-10

Effective Date: 07/01/2009 TN No.: 05-005

Attachment 3.1-A.1 Page 7c.5a

4.b.(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Description of Services

(f) Mobile Crisis Management This involves all supports, services and treatments necessary to provide integrated crisis response, crisis stabilization interventions and crisis prevention activities. It is available 24/7/365 and provides immediate evaluation, triage and access to acute MH/DD/SAS services, treatment, supports to effect symptom reduction, harm reduction and/or to safely transition persons in acute crisis to the appropriate environment for stabilization. It is provided by a team that includes a Qualified Professional who must be either, a nurse, a clinical social worker or psychologist. Teams include substance abuse professionals, and a psychiatrist must be available for face to face or telephone consults. Paraprofessionals with crisis management experience may also be included on the team but must work under the supervision of a professional. Experience with the appropriate disability group is required and 20 hours of crisis intervention training within the first 90 days of employment is necessary. The maximum length of the service is 24 hours per episode and prior authorization will be required after the first 8 hours for the remaining 16 hours. Documentation must include: a service note that includes the recipient’s name, Medicaid identification number, date of service, purpose of contact, describes the provider’s interventions, includes the time spent performing the interventions, effectiveness of the intervention, and the signature of the staff providing the service.

NOTE: This has a limitation; however the service requires stabilization or movement into an environment that can stabilize so it is not really a termination of service.

____________________________________________________________________________________ TN No.: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No.: NEW

Attachment 3.1-A..1 Page 7c.6

4.b.(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Description of Services

(g) Intensive In-Home A time limited mental health/substance abuse service that can be provided through age 20 in order to: • diffuse current crisis as a first responder, • intervene to reduce likelihood of re-occurrence, • ensure linkage to community services and resources, • monitor and manage presenting psychiatric and/or addictions, • provide self-help and living skills for youth; and • work with caregivers in implementation of home-based supports and other

rehabilitative supports to prevent out of home placement for the child.

This is a team service provided by qualified professionals, associate professionals and paraprofessionals. There is a team to family ratio to keep case load manageable and staff must complete intensive in home training with in the first 90 days of employment. Services are provided in the home or community and not billable for children in detention or inpatient settings. The service requires a minimum of 12 face to face contacts the first month with a contact being defined as all visits within a 24 hour period. A minimum of 2 hours of service must be provided each day for the service to be billable. Number of visits per month for the second and third month of the service will be titrated with the expectation of six visits per month. Documentation must include: a daily full service note that includes the recipient’s name, Medicaid identification number, date of service, purpose of contact, describes the provider’s interventions, includes the time spent performing the interventions, effectiveness of the intervention, and the signature of the staff providing the service. The provider agency must be certified and enrolled as a Critical Access Behavioral Health Care Agency by July 1, 2009. The service must be ordered by a physician, licensed psychologists, physician’s assistant or nurse practitioner and prior approval will be required via the statewide UR vendor or by an approved LME contracted with the Medicaid Agency and meeting the same standards and requirements as the statewide vendor. This initial prior approval process will ensure that the level of the service is appropriate and concurrent reviews will determine the ongoing medical necessity for the service or the need to move up or down the continuum of services to another level of care.

This service can only be provided by one Intensive In-Home provider at the time and cannot be billed on the same day as Multisystemic Therapy, Day Treatment, Hourly Respite, Individual, group or family therapy, SAIOP, or living in a Level II-IV child residential or substance abuse residential facility.

_____________________________________________________________________________________ TN No.: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No.: 05-005

Attachment 3.1-A.1 Page 7c.7

4.b.(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Description of Services

(h) Multisystemic Therapy (MST) This mental health/substance abuse program is an evidenced-based practice designed for youth generally between the ages of 7 and 17 who have antisocial, aggressive/violent behaviors and are at risk for out of home placement due to delinquency; adjudicated youth returning from out of home placement and/or chronic or violent juvenile offenders; and youths with serious emotional disturbances or abusing substances. As required by EPDST, youth outside of these age ranges would be able to receive the service if medically necessary and if no other more appropriate service is available. This is a team service that has the ability to provide service 24/7/365. The services include assessment, individual therapeutic interventions with the youth and family, case management, and crisis stabilization. Specialized therapeutic interventions are available to address special areas such as substance abuse, sexual abuse, sex offending, and domestic violence. The service must be ordered by a physician, licensed psychologists, physician’s assistant or nurse practitioner and prior approval will be required via the statewide UR vendor or by an approved LME contracted with the Medicaid Agency and meeting the same standards and requirements as the statewide vendor. This initial prior approval process will ensure that the level of the service is appropriate and concurrent reviews will determine the ongoing medical necessity for the service or the need to move up or down the continuum of services to another level of care.

A minimum of 12 contacts are required within the first month of the service and for the next two months an average of 6 contacts per month will occur. It is the expectation that service frequency will be titrated over the last two months. Documentation must include: a daily full service note that includes the recipient’s name, Medicaid identification number, date of service, purpose of contact, describes the provider’s interventions, includes the time spent performing the interventions, effectiveness of the intervention, and the signature of the staff providing the service.

Clinical criteria (medical necessity criteria for admission and continued stay) are embedded in the service definition. The provider qualifications are at a minimum a master’s level QP who is the team supervisor and three QP staff. Staff is required to participate in MST introductory training and quarterly training on topics related to the needs of MST youth and their family on an ongoing basis. All MST staff shall receive a minimum of one hour of group supervision and one hour of telephone consultation per week from specially trained MST supervisors. Limitations are in place to prevent reimbursement for duplication of services.

TN No.: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No.: 05-005

Attachment 3.1-A.1 Page 7c.8

4.b.(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Description of Services

(i) Substance Abuse Intensive Outpatient (SAIOP) This service provides motivational enhancement and engagement therapies for recovery, random alcohol/ drug testing and strategies for relapse prevention to include community and/or other strategies for relapse preventions. These therapies include: • Individual counseling and support, • Group counseling and support, • Family counseling and support, • Biochemical assays to identify recent drug use (e.g. urine drug screens), • Strategies for relapse prevention: community and social support systems in

treatment, • Crisis contingency planning, • Disease management; and • Treatment support activities that have been adapted or specifically designed for persons with physical disabilities or persons with co-occurring disorders of mental illness and/or developmental disabilities and/or substance abuse/dependence.

Family counseling and support as well as group counseling and support are provided only for the direct benefit of the recipient of the SAIOP program.

SAIOP must be available for a minimum of 3 hours per day, be operated out of a licensed substance abuse facility and can be provided in a variety of settings. The maximum face to face ratio is an average of not more than 12 recipients to 1 direct services staff based on average daily attendance. Documentation must include: a service note that includes the recipient’s name, Medicaid identification number, date of service, purpose of contact, describes the provider’s interventions, includes the time spent performing the interventions, effectiveness of the intervention, and the signature of the staff providing the service. This service can only be provided by qualified substance abuse professional staff with the following licenses or certifications: Licensed Psychological Associates, Licensed Professional Counselors, Licensed Clinical Social Workers, Certified Substance Abuse Counselors, and Licensed Clinical Addiction Specialists. This service must be ordered by an MD, NP, PA or PhD psychologist. Prior approval will be required via the statewide UR vendor or by an approved LME contracted with the Medicaid Agency and meeting the same standards and requirements as the statewide vendor. This initial prior approval process will ensure that the level of the service is appropriate and concurrent reviews will determine the ongoing medical necessity for the service or the need to move up or down the continuum of services to another level of care.

TN No.: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No.: 05-005

Attachment 3.1-A.1 Page 15a.1

13. D. Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services

Description of Services

(i) Evaluation/Assessments/ Psycho-therapy/Behavioral Health Counseling For the complete description of the service, see Attachment 3.1-A.1 pages 15a.14 and 15a.15. (In accordance with 42 CFR 440.130)

(ii) Diagnostic Assessment This is a clinical face to face evaluation of a recipient’s MH/DD/SAS condition that will establish a need for the enhanced benefit package of services. It is a team service and must include evaluations by either, a physician, physician assistant, nurse practitioner or licensed psychologist who can sign an order for services and a licensed or certified practitioner with expertise in MH/DD/SAS as appropriate and consist of the following: • a chronological general health and behavioral health history (includes both mental health and substance abuse) of the recipient’s symptoms, treatment, treatment response and attitudes about treatment over time, emphasizing factors that have contributed to or inhibited previous recovery efforts; biological, psychological, familial, social, developmental and environmental dimensions and identified strengths and weaknesses in each area; • a description of the presenting problems, including source of distress, precipitating events, associated problems or symptoms, recent progressions, and current medications; • a strengths/problem summary which addresses risk of harm, functional status, co- morbidity, recovery environment, and treatment and recovery history; • diagnoses on all five (5) axes of DSM-IV; • evidence of an interdisciplinary team progress note that documents the team’s review and discussion of the assessment; • a recommendation regarding target population eligibility; and • evidence of recipient participation including families, or when applicable, guardians or other caregivers.

Documentation must include the following elements: • a chronological general health and behavioral health history (includes both mental health and substance abuse) of the recipient’s symptoms, treatment, treatment response and attitudes about treatment over time, emphasizing factors that have contributed to or inhibited previous recovery efforts; biological, psychological, familial, social, developmental and environmental dimensions and identified strengths and weaknesses in each area; • a description of the presenting problems, including source of distress, precipitating events, associated problems or symptoms, recent progressions, and current medications; • strengths/problem summary which addresses risk of harm, functional status, co- morbidity, recovery environment, and treatment and recovery history; • diagnoses on all five (5) axes of DSM-IV; • evidence of an interdisciplinary team progress note that documents the team’s review and discussion of the assessment;

______________________________________________________________________________________ TN No.: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No.: 05-005

Attachment 3.1-A.1 Page 15a.3

13. D. Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Description of Services (42 CFR 30.130(a))

• a recommendation regarding target population eligibility; and • evidence of recipient participation including families, or when applicable, guardians or other caregivers.

All other services in this section are covered in 42 CFR 440.130(d ).

(iv) Psychosocial Rehabilitation This service provides skills development, educational and prevocational activities: • Community living such as house keeping, shopping, cooking, use of transportation facilities, money management, • Personal care such as health care, medication self management, grooming, • Social relationships, • Educational activities which include assisting client in securing needed educational services such as adult basic education and special interest courses; and • Prevocational activities which focus on development of positive work habits and participation on activities that increase participant’s self worth, purpose and confidence. These activities are not to be job specific training.

It is available for a period of 5 or more hours per day. The interventions must be included in a treatment plan and may be any of the following: behavioral interventions/management, social and other skill development, adaptive skill training, enhancement of communication and problem solving skills, anger management, family support, medication monitoring, monitoring of changes in psychiatric symptoms/or functioning and positive reinforcement. Program assurance that there should be a supportive, therapeutic relationship between providers and the recipient. It is provided in a licensed facility with staff to recipient ratio of 1:8. This service is provided to outpatients by a mental health organization that meets State licensure requirements, and providers of the services will meet the appropriate Federal requirements or the State requirements. Documentation must include: a weekly full service note that includes the recipient’s name, Medicaid identification number, date of service, purpose of contact, describes the provider’s interventions, includes the time spent performing the interventions, effectiveness of the intervention, and the signature of the staff providing the service. This service must be ordered by an MD, NP, PA or PhD psychologist. Prior approval will be required via the statewide UR vendor or by an approved LME contracted with the Medicaid Agency and meeting the same standards and requirements as the statewide vendor. This initial prior approval process will ensure that the level of the service is appropriate and concurrent reviews will determine the ongoing medical necessity for the service or the need to move up or down the continuum of services to another level of care.

The Psychosocial Rehabilitation program shall be under the direction of a person who meets the requirements specified for Qualified Professional status. The Qualified Professional is responsible for supervision of other program staff which may include Associate Professionals and Paraprofessionals. All staff must have the knowledge, skills, and abilities required by the population and age to be served.

___________________________________________________________________________________ TN No.: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No.: 07-003

Attachment 3.1-A.1 Page 15a.3a

13. D. Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Description of Services (42 CFR 30.130(a))

Provider agencies for Psychosocial Rehabilitation are licensed by the Division of Health Service Regulation, endorsed by the LMEs as meeting the program specific requirements for provision of Psychosocial Rehabilitation and enrolled in Medicaid. The staffs providing this service are employees of the enrolled agency. Their qualifications and the discrete service components they perform are listed below.

The Psychosocial Rehabilitation program shall be under the direction of a person who meets the requirements specified for Qualified Professional status. The Qualified Professional is responsible for supervision of other program staff which may include Associate Professionals and Paraprofessionals. All staff must have the knowledge, skills, and abilities required by the population and age to be served.

The following sets forth the activities included in this service definition. These activities reflect the appropriate scope of practice for the Psychosocial Rehabilitation program staff identified below.

Qualified Professional: In addition to the following activities, the Qualified Professional may provide any activity listed under Associate Professional or Paraprofessional: case management components; developing, implementing, and monitoring the Person Centered Plan; behavioral interventions/management; social and other skill development, adaptive skill training; enhancement of communication and problem solving skills, anger management, family support, medication monitoring, monitoring of changes in psychiatric symptoms/or functioning.

Associate Professional: In addition to the following activities, the Associate Professional may provide the activities listed under Paraprofessionals: behavioral interventions/management; social and other skill development, adaptive skill training; enhancement of communication and problem solving skills, anger management, family support, medication monitoring, monitoring of changes in psychiatric symptoms/or functioning.

Paraprofessional: Community living, such as housekeeping, shopping, cooking, use of transportation facilities, money management; personal care such as health care, medication self- management, grooming; social relationships; use of leisure time; prevocational activities which focus on the development of positive work habits; assisting the client in securing needed education services.

Operating Requirements

Each facility shall have a designated program director. A minimum of one staff member on-site to each eight or fewer clients in average daily attendance shall be maintained.

_____________________________________________________________________________________ TN No.: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No. NEW

Attachment 3.1-A.1 Page 15a.6

13. D. Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Description of Services

(vii) Community Support Team (CST) - (adults) Services provided by this team consist of mental health and substance abuse services and supports necessary to assist adults in achieving rehabilitation and recovery goals. It assists individuals to gain access to necessary services; reduce psychiatric and addiction symptoms; and develop optimal community living skills. The services include assistance and support to individuals in crisis situation; service coordination; psycho education and support for individuals and their families; independent living skills; development of symptom monitoring and management skills, monitoring medications and self- medication. • Assist individuals to gain access to necessary services to reduce psychiatric and addiction symptoms, • Assistance and support for individuals in crisis situations, • Service coordination, • Psycho-education, • Individual restorative interventions for development of interpersonal, community coping and independent living skills; and • Monitoring medications and self medication.

Documentation must include: a service note that includes the recipient’s name, Medicaid identification number, date of service, purpose of contact, describes the provider’s interventions, includes the time spent performing the interventions, effectiveness of the intervention, and the signature of the staff providing the service.

The CST provider assumes the role of advocate, broker, coordinator and monitor of the service delivery system on the behalf of the recipient. The service must be ordered and prior approval will be required. A CST team will be comprised of 3 staff persons one of which is the team leader and must be a QP. The other two may be a QP, AP or a paraprofessional. The team maintains a consumer to practitioner ratio of no more than fifteen consumers per staff person. All staff providing this service must have a minimum of one year documented experience with the adult population and completion of a minimum of twenty hours of crisis management and community support team service definition required within the first 90 days of hire. Clinical criteria are imbedded in the definition as well as service limitations to prevent duplication of services. It must be ordered by either, a physician, physician assistant, nurse practitioner or licensed psychologist. The provider agency must be certified and enrolled as a Critical Access Behavioral Health Care Agency by July 1, 2009. Prior approval will be required via the statewide UR vendor or by an approved LME contracted with the Medicaid Agency and meeting the same standards and requirements as the statewide vendor. This initial prior approval process will ensure that the level of the service is appropriate and concurrent reviews will determine the ongoing medical necessity for the service or the need to move up or down the continuum of services to another level of care.

NOTE: This service is used as an intervention to avoid need for a higher level of care or as a step down from a higher level of care. It is an ACTT “lite” service.

TN No: 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No: 07-003

Attachment 3.1-A.1 Page 15a.16

13. D. Behavioral Health Rehabilitative Services (continued)

Provider Qualifications for Staff Employed by Agencies Enrolled with Medicaid

Services under this section are provided by licensed practitioners or programs/agencies for the mentally ill, developmentally disabled and substance abusers certified as clinical addiction specialists and clinical supervisors meeting the program standards of the Commission on Mental Health, Developmental Disabilities and Substance Abuse Services; and who are directly enrolled with Medicaid. These services are available to categorically needy and medically needy recipients. They are provided under a sunset clause by certified or privileged staff of Local Management Entities (LME) directly enrolled with Medicaid. Services include the following:

1. Outpatient Psychotherapy (billed under CPT codes between 90801 through 90857) found in the psychiatric code section of the CPT book. These codes include outpatient psychotherapy codes including individual insight oriented, behavior modifying, and/or supportive psychotherapy; interactive psychotherapy; family psychotherapy; and group psychotherapy. Service can be billed by all licensed clinicians according to their scope of practice.

2. Psychological Testing, Developmental Testing, and Neuro-behavioral Testing (described in section/billed under CPT codes between 96100 through 96117). Services can only be billed by PhD and Master’s Level Psychologist. These codes include psychological testing; developmental testing; neurobehavioral status examinations; and neuropsychological testing.

3. Behavioral Health Assessment* and Counseling as described in the HCPCS book, under the following codes:

 H0031 Mental health assessment (a non-physician assessment),

 H0004 Behavioral health counseling and therapy (modifiers are added to match CPT codes for group counseling, and for family therapy), and

 H0005 Alcohol and/or drug services; group counseling by a clinician (substance abuse group counseling).

* Certified Clinical Addictions Specialists (CCAS) and Certified Clinical Supervisors (CCS) can only bill for the three HCPCS codes identified above.

TN No. 09-017 Supersedes

Approval Date: 02-04-10 Effective Date: 07/01/2009 TN No. 04-011

Attachment 4.19-B Supplement 1, Page 1a

State Plan Under Title XIX of the Social Security Act Medical Assistance Program State: North Carolina

Payments for Medical and Remedial Care and Services

Payment for Rehabilitation Services:

FY 2005 and 2006 – No rate increase from the June 30, 2005 rate for all Medicaid private and public providers with the following exceptions: federally qualified health clinics, rural health centers, state institutions, outpatient hospital, pharmacy and the non- inflationary components of the case-mix reimbursement system for nursing facilities.

NC General Assembly legislation mandates that effective July 1, 2005, reimbursement rates for Rehabilitation Services for the state fiscal years 2005-2006 and 2006-2007 will remain at the rate in effect as of June 30, 2005, except Medicaid rates may be adjusted downward in accordance with the current year’s downward adjustments to the Medicare fee schedule.

SFY 2010 – The rates for SFY2010 are frozen as of the rates in effect at July 1, 2009 except Medicaid rates may be adjusted downward in accordance with the current year’s downward adjustments to the Medicare fee schedule. Effective October 1, 2009, an overall program reduction of 4.68% was applied. There will be no further annual adjustment.

SFY 2011 – The rates for SFY2011 are frozen as of the rates in effect at July 1, 2010. There will be no further annual adjustment.

Reference: Attachment 4.19-B, Section 13 .

TN No. 09-017 Supersedes

Approval Date: 02-04-10

Eff. Date 07/01/2009 TN No. 07-003

ARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

.LTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 RANSMITTAL AND NOTICE OF APPROVAL OF | !. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 09-017 NC JR: HEALTH CARE FINANCING ADMINISTRATION | 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) ): REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES July 1, 2009 TYPE OF PLAN MATERIAL (Check One): ] NEW STATE PLAN — AMENDMENT TO BE CONSIDERED AS NEW PLAN (.] AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) FEDERAL STATUTE/REGULATION CITATION: 7, FEDERAL BUDGET IMPACT: a. FFY 2010 ($24,727,244) Section 1915(g)(1) b. FFY 2011 ($19,912,398) PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION [TACHMENT: OR ATTACHMENT (If Applicable): tachment 4.19-B, Supplement 1, Page 1a Attachment 4.19-B, Supplement 1, Page 1a

. SUBJECT OF AMENDMENT:

shabilitation Services

. GOVERNOR’S REVIEW (Check One): [_] GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: SECRETARY (-] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED (_] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

16. RETURN TO:

Office of the Secretary

Department of Health and Human Services 2001 Mail Service Center

Secretary Raleigh, North Carolina 27699-2001

BAG OU"™ |

FOR REGIONAL OFFICE USE ONLY

7. DATE RECEIVED: 18. DATE APPROVED:

09/29/09 02/04/10 PLAN APPROVED — ONE COPY ATTACHED 9. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 07/01/00 1. TYPED NAME: 22 TIT EB: Abting Agdociate Regional Administrator Mary Kaye Justis. RN. MBA Division af Wedicaid & Children’s Health Opns 3. REMARKS:

Approved with following changes as authorized by State Agency on email dated 02-05-10:

Block # 8 Attachment 4.19-B changed to read Attachment 4.19-B Supplement 1, page la and 3.1-A.1 pages 7c. 1, 7¢.2, 7¢.3. 7e.3e. 7¢.4. 7¢.5, 7¢.5a.7¢.6. 7¢.7. 7.8, 15a.1, 15a.3. 15a.3a, 15a.6 and 15a.16: Block #9 Attachment 4.19-B changed to read: Attachment 4.19-B Supplement |. page la and 3.1-A.1 pages 7c.1. 7.2. 7¢.3. 7¢.3e. 7.4, 7.5, 7¢.5a,7¢.6, 7¢.7, 70.8, 15a.1, 15a.3, 15a.3a. 15a.6 and 15a.16:

\(M HCFA-179 (07-92)

Table of Contents

State/Territory Name: North Carolina State Plan Amendment (SPA) #: 11-020 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

Department of Health & Human Services C/I. Ay Centers for Medicare & Medicaid Services

61 Forsyth St., Suite 4T20

Atlanta, Georgia 30303-8909 CENTERS for MEDICARE & MEDICAID SERVICES

October 24, 2011

Craigan Gray, MD, MBA, JD

Director

Division of Medical Assistance

North Carolina Department of Health and Human Services 2501 Mail Service Center

Raleigh, North Carolina 27699-2501

Attention: Teresa Smith RE: North Carolina Title XIX State Plan Amendment, Transmittal #11-020 Dear Dr. Gray:

We have reviewed the proposed amendment to the North Carolina Medicaid State Plan that was submitted under transmittal number 11-020 and received in the Atlanta Regional Office on July 26, 2011.

This amendment is required due to the State administrative decision to adjust the supplemental page for dental services. The State Plan change is to adjust the SFY 2012 rates by a negative 2.67 percent to yield a 12 month 2 percent reduction in the 8 remaining months of this SFY. For SFY 2013, the rates will be adjusted such that they will equal 98 percent of the rate in effect July 1, 2011.

Based on the information provided, Medicaid State Plan Amendment 11-020 was approved on October 20, 2011. The effective date of this amendment is November 1, 2011. We are enclosing the approved form HCFA- 179 and plan page.

If you have any questions or need any further assistance, please contact Yvette Moore at (404) 562-7327.

Sincerely, /s/

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations Enclosures

DEPARTMENT OF HEALTH AND HUMAN SERVICES

HEALTH CARE FINANCING ADMINISTRATION Oem NO. 0988-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL son wc

FOR: HEALTH CARE FINANCING ADMINISTRATION

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

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

4. PROPOSED EFFECTIVE DATE

October 1, 2011

5. TYPE OF PLAN MATERIAL (Check One):

(J NEW STATE PLAN [J] AMENDMENT TO BE

CONSIDERED AS NEW PLAN

( AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS ANAMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

42 CFR 440.100

7, FEDERAL BUDGET IMPACT: a. FFY 2012 ($5,212,280) b. FFY 2013 $7,262,113

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-B, Supplement 3, Page la

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

Attachment 4.19-B, Supplement 3, Page la

10. SUBJECT OF AMENDMENT:

Dental

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

12. SIGNATURE OF STATE AGENCY OFFICIAL: isi

—X] OTHER, AS SPECIFIED: SECRETARY

16. RETURN TO: Office of the Secretary

13. TYPED NAME: Lanier M. Cansler

Department of Health and Human Services 2001 Mail Service Center

14. TITLE: Secretary

Raleigh, North Carolina 27699-2001

15. DATE SUBMITTED: 07/25/11

FORM HCFA-179 (07-92)

Attachment 4.19-B Section 12, Page 2

MEDICAL ASSISTANCE State: NORTH CAROLINA

PAYMENTS FOR MEDICAL AND REMEDIAL CARE AND SERVICE

THIS PAGE INTENTIONALLY LEFT BLANK

TN No.: 11-020 Supersedes Approval Date: 10-20-11 Effective Date: 11/1/2011 TN No.: 88-12

Attachment 4.19-B Supplement 3, Page la

State Plan Under Title XIX of the Social Security Act Medical Assistance Program State: North Carolina

Payments for Medical and Remedial Care and Services

Payment for Dental:

FY 2007 - Effective January 1, 2007 inflationary increases were applied to the following program:

Dental providers received an increase of 23.61%,

SFY 2009 — The rates for Dental Services are frozen at the rates in effect on December 31, 2008.

SFY 2010 — The rates for SFY 2010 are frozen as of the rates in effect at July 1, 2009. Effective October 1, 2009, a negative inflationary adjustment of 5.79% as applied to the existing rates. There will be no further annual adjustment.

SFY 2011 — As of July 1, 2010 rates will be frozen.

SFY 2012 — Rates will be frozen at the rate in effect on June 30, 2011. Effective October 1, 2011, existing rates are adjusted by a negative 2.67% to yield a twelve (12) month two percent (2%) reduction in the nine (9) remaining months of this State Fiscal Year. Exception: Reimbursement rates paid for composite fillings for back teeth were reduced by 15% (except for D2391 which was reduced by 5%) and a 10% increase as applied to rates paid for amalgam fillings for back teeth.

SFY 2013 - Effective July 1, 2012, the rates will be adjusted such that they will equal 98% of the rate in effect July 1, 2011. There will be no further annual adjustments this state fiscal year. Exception: The rates are frozen at the October 1, 2011 rates for composite fillings for back teeth and for amalgam fillings for back teeth.

Reference: Attachment 4.19-B, Section 10

TN- No. 11-020 Supersedes Approval Date: 10-20-11 Eff. Date: 11/01/11 TN-No. 09-013

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 11-020 NC

FOR: HEALTH CARE FINANCING ADMINISTRATION

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

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

4. PROPOSED EFFECTIVE DATE

October 1, 2011

| 5. TYPE OF PLAN MATERIAL (Check One):

(J NEW STATE PLAN —) AMENDMENT TO BE

CONSIDERED AS NEW PLAN

(] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS ANAMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

42 CFR 440.100

7, FEDERAL BUDGET IMPACT: a. FFY 2012 ($5,212,280) b. FFY 2013 $7,262,113

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-B, Supplement 3, Page la

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

Attachment 4.19-B, Supplement 3, Page la

10. SUBJECT OF AMENDMENT:

Dental

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

12. SIGNATURE OF STATE AGENCY OFFICIAL: //siI

{] OTHER, AS SPECIFIED: SECRETARY

16. RETURN TO: Office of the Secretary

13. TYPED NAME: Lanier M. Cansler

Department of Health and Human Services 2001 Mail Service Center

14, TITLE: Secretary

Raleigh, North Carolina 27699-2001

15. DATE SUBMITTED: 07/25/11

17. DATE RECEIVED O7/26/11

Block # 8 chatg :

Block # 9 chang

ociate Regional Administrator i Children Health Opns__

ie agency dated 09/29/11 and 10/11

ee

FORM HCFA-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

June 7, 2013

Ms. Carol Steckel, Director North Carolina Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive 2501 Mail Service Center Raleigh, North Carolina 27699-2501

Re: Title XIX State Plan Amendment, Transmittal #13-004

Dear Ms. Steckel:

We have reviewed the proposed State Plan Amendment NC-13-004, which was submitted to the Atlanta Regional Office on December 21, 2012. This amendment establishes a new eligibility group for the family planning services converting the Waiver to the state plan option that requires the state to: 1) cover the same family planning services that categorically needy beneficiaries receive; 2) cover at least one family planning-related service; 3) impose no restrictions for eligibility based on age to receive family planning services; and 4) provide non-emergency medical transportation to beneficiaries to and from family planning appointments.

Based on the information provided, the Medicaid State Plan Amendment NC-13-004 was approved on June 7, 2013. The signed HCFA form 179 and the approved plan pages are enclosed. The effective date of this amendment is November 1, 2013.

If you have any additional questions or need further assistance, please contact Rita Nimmons at (404-562-7415) or Rita.Nimmons@CMS.hhs.gov.

Sincerely,

/s/

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosure(s)

ATTACHMENT 3.1-A

Page 9

OMB NO.:

State/Territory: North Carolina___________

Citation

Family Planning Benefits 1905(a)(4)(C) 4.c.(i) Family planning services and supplies for individuals of child-bearing age and for individuals eligible pursuant to Att. 2.2-A, B, if this eligibility option is elected by the State. Provided: No limitations

With limitations Please describe any limitations: The State of North Carolina will limit coverage for family planning-related services (inter-periodic visits) based on the potential for over-scheduling of unnecessary visits for beneficiaries and abuse by physicians. North Carolina will provide coverage of family planning visits should be due to the medical necessity of the beneficiary. The State will cover a total of a six inter-periodic visit limitation annually, not to include the annual exam, which is also considered to be a periodic visit. The State’s limitations on the number of family planning visits per beneficiary is based on historical utilization of family planning services under the waiver demonstration, which has consistently shown an average of no more than two visits per beneficiary per year.

4.c.(ii) Family planning-related services provided under the above State Eligibility Option Under the State Eligibility Option for Family Planning Services, the State will cover screening and treatment for sexually transmitted infections, which will be performed pursuant to or subsequent to an annual exam. The State will also cover screening for HIV, which will be performed pursuant to or subsequent to an annual exam. The result is that screening and treatment for sexually transmitted infections will be covered during the annual exam or during in any or all of the six subsequent inter- periodic visits allowed under the program. Screening for HIV will be covered during the annual exam or during any or all of the six subsequent inter-periodic visits allowed under the program.

TN. No. 13-004

Approval Date: 06-07-13 Effective Date: 11/01/2013 Supersedes TN. No. 11-040

Revision:

CMS-PM-

ATTACHMENT 2.2-A

Page 23g

OMB No.:

State/Territory: North Carolina

Citation

Groups Covered

B. Optional Groups Other Than the Medically Needy

(Continued) 1902(a)(10)(A)(ii)(XXI)

1902(ii) Individuals who are not pregnant and whose income does not exceed the State established income standard of 185% of the Federal Poverty Level. This amount does not exceed the highest income limit for pregnant women in this State Plan, which is 185% of the Federal Poverty Level. In determining eligibility for this group, the State considers only the income of the applicant or beneficiary. * See note below.

*For married persons living together, North Carolina considers the spouse’s income of the applicant or beneficiary in determining eligibility for family planning services. In determining eligibility for family planning services, North Carolina will consider the parents’ incomes for a child under age 21 applicant or beneficiary, if the child applicant or beneficiary lives with the parents. Note: Services are limited to family planning services and family planning- related services as described in section 4.c(ii) of Attachment 3.1-A. 1920C Presumptive Eligibility for Family Planning:

The State provides a period of presumptive eligibility for family planning services to individuals determined by a qualified entity, based on preliminary information from the individual, described in the group the State has elected to make eligible under the above option. The period of presumptive eligibility ends on the earlier of the date a formal determination of Medicaid eligibility is made under 1902(a)(10)(A)(ii)(XXI), or, when no application has been filed, the last day of the month following the month during which the qualified entity determines the individual presumptively eligible.

TN. No. 13-004

Approval Date: 06-07-13 Effective Date: 11/01/2013 Supersedes TN. No. 11-040

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

1. TRANSMITTAL NUMBER: 2. STATE

13-004 NC 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

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

4. PROPOSED EFFECTIVE DATE

November 1, 2013

5. TYPE OF PLAN MATERIAL (Check One):

(NEW STATE PLAN LJ AMENDMENT TO BE

CONSIDERED AS NEW PLAN —] AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AME

INDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

Section 2303 of the Affordable Care Act

7. FEDERAL BUDGET IMPACT: a. FFY 2014 $155,000 b. FFY 2015 $164,416

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 2.2-A, page 23g and Attachment 3.1-A, Page 9

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

Attachment 2.2-A, page 23g and Attachment 3.1-A, Page 9

10. SUBJECT OF AMENDMENT: Family Planning Services

11. GOVERNOR’S REVIEW (Check One): (1 GOVERNOR’S OFFICE REPORTED NO COMMENT (] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED

LJ) NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

) OTHER, AS SPECIFIED: SECRETARY

Aldona Z. Wos, M.D.

12. SIGNATURE OF § AGENCY OFFICIAL: 16. RETURN TO: Ve ZES 13. TYPED NAME: Office of the Secretary

Department of Health and Human Services

14. TITLE: Secretary

2001 Mail Service Center Raleigh, North Carolina 27699-2001

15. DATE SUBMITTE

arch 15, 3013 Ag

FORM HCFA-179 (07-92)

CMCS/OSG: 12/2/13 _____________________________________________________________________________

Table of Contents State/Territory Name: North Carolina State Plan Amendment (SPA) #:13-013 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 179 3) Approved SPA Pages

‘

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office

61 Forsyth Street, Suite 4T20 Cc M Ss

Atlanta, Georgia 30303 CENTERS FOR MEDICARE & MEDICAID SERVICES

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

December 11, 2013

Ms. Sandra Terrell, MS, R.N., Acting Director Division of Medical Assistance

Department of Health and Human Services 2501 Mail Service Center

Raleigh, NC 27699-2501

Re: North Carolina Title XIX State Plan Amendment, Transmittal 13-013

We have reviewed the proposed State Plan Amendment TN 13-013, which was submitted on September 24, 2013. This amendment implements a rate freeze for Durable Medical Equipment in North Carolina for fiscal years 2014 and 2015.

Based on the information provided, the Medicaid State Plan Amendment NC 13-013 was approved on December 11, 2013. The effective date of this amendment is August 1, 2013. We are enclosing the HCFA Form 179 and the approved plan pages.

If you have any additional questions or need further assistance, please contact Clarence Lewis at 803-898-7647, or Donald Graves at 919-828-2999.

Sincerely,

Jackie Glaze Associate Regional Administrator Division of Medicaid and Children’s Health Operations

a

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13-013 NC KA 3, PROGRAM IDENTIFICATION. FOR: HEALTH CARE FINANCING ADMINISTRATION TITLE XIX OF THE Sociny ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4, PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION August 1, 2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One):

(J) NEW STATE PLAN (J AMENDMENT TO BE CONSIDERED AS NEW PLAN i) AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 7, FEDERAL BUDGET IMPACT:

6. FEDERAL STATUTE/REGULATION CITATION: aFFY2014 $0.00

42 ‘CFR 440.200. bFFY 2015 $0.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: | 9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (if Applicable): Attachment 4.19-B, Supplement 2, page 1b Attachment 4.19-B, Supplement 2, page Ib

Attachment 4.19-B, Supplement 2, Page 1b.1

10. SUBJECT OF AMENDMENT. Durable Medical Equipment (DME)

i 1, GOVERNOR’S REVIEW (Check One): (] GOVERNOR'S OFFICE REPORTED NO COMMENT J OTHER, AS SPECIFIED; Secretary (J COMMENTS OF GOVERNOR’S OFFICE ENCLOSED (] NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

12. S$) e AGENCY OFFICIAL: 16. RETURN TO: 13. TYPED NAME: aa) Office of the Secretary

“AldonaZ. Wos, MD. Department of Health and Human Services ite 2001 Mail Service Center

Secretary tog Raleigh, NC 27699-20014

FOR REGIONAL OFFICE USE ONLY

17, DATE RECEIVED: 18. DATE APPROVED: 12-11-13 09-24-13

i PLAN APPROVED — ONE. COPY ATTACHED. 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF B 08-01-13 . 1. TYPED NAME: 3 : Regi istrator ‘ckie Glaze i of Medicaid & Children Health Opns

23. REMARKS:

Attachment 4.19-B Supplement 2, Page 1b

State Plan Under Title XIX of the Social Security Act Medical Assistance Program State: North Carolina

Payments for Medical and Remedial Care and Services

Payment for Medical Equipment: SFY 2003 — No adjustment. SFY 2004 — No adjustment for Durable Medical Equipment effective August 1, 2003.

SFY 2005 and 2006 — No rate increase from the June 30, 2005 rate for all Medicaid private and public providers with the following exceptions: federally qualified health clinics, rural health centers, state institutions, outpatient hospital, pharmacy and the non-inflationary components of the case-mix reimbursement system for nursing facilities.

NC General Assembly legislation mandates that effective July 1, 2005, reimbursement rates for

Medical Equipment for the state fiscal years 2005-2006 and 2006-2007 will remain at the rate in effect as of June 30, 2005 except Medicaid rates may be adjusted downward in accordance with

the current year’s downward adjustments to the Medicare fee schedule.

SFY 2010 — The rates for SFY 2010 are frozen as of the rates in effect at July 1, 2009, except Medicaid rates may be adjusted downward in accordance with the current year’s downward adjustments to the Medicare fee schedule. Effective October 1, 2009, an overall rate adjustment of -4.16% was applied to the existing rates. There will be no further annual adjustment.

SFY 2011 — For SFY 2011, the rate will be frozen at the rate in effect on June 30, 2010.

SFY 2012 — Rates will be frozen at the rate in effect on June 30, 2011. Effective November 1, 2011, existing rates are adjusted by a negative 2.66% to yield a twelve (12) month two percent (2%) reduction in the nine (9) remaining months of this State Fiscal Year.

SFY 2013 — Effective July 1, 2012, the rates will be adjusted such that they will equal 98% of the rate in effect July 1, 2011. There will be no further annual adjustments this state fiscal year except that Medicaid rates may be adjusted downward in accordance with the current years downward adjustments to the Medicare fee schedule.

SFY 2014 — As of July 1, 2013 rates will be frozen as in effect June 30, 2013. There will be no further adjustments except that Medicaid rates may be adjusted downward in accordance with the applicable years downward adjustments to the Medicare fee schedule.

Reference: Attachment 4.19-B, Section 7, Page 4

TN. No: 13-013 Supersedes Approval Date: 12-11-13 Eff. Date 08/01/13 TN. No: 11-019

Attachment 4.19-B Supplement 2, Page 1b.1

State Plan Under Title XIX of the Social Security Act Medical Assistance Program State: North Carolina

Payments for Medical and Remedial Care and Services

Payment for Medical Equipment Continued:

SFY 2015 - As of July 1, 2014 rates will be frozen as in effect June 30, 2014. There will be no further adjustments except that Medicaid rates may be adjusted downward in accordance with the applicable years downward adjustments to the Medicare fee schedule.

Reference: Attachment 4.19-B, Section 7, Page 4

TN. No: NEW Supersedes Approval Date:12-11-13 Eff. Date 8/01/13

TN. No:

_____________________________________________________________________________

Table of Contents State/Territory Name: North Carolina State Plan Amendment (SPA) #: NC-13-0014-MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

December 11, 2013

Ms. Sandra D. Terrell, MS, R.N. Acting Director Division of Medical Assistance North Carolina Department of Health and Human Services 2501 Mail Service Center Raleigh, North Carolina 27699-2501

Attention: Teresa Smith

RE: North Carolina Title XIX State Plan Amendment, Transmittal # NC 13-0014-MM1

Dear Ms. Terrell:

Enclosed is an approved copy of North Carolina’s State Plan Amendment (SPA) 13-0014-MM1, which was submitted to CMS on September 26, 2013. SPA 13-0014-MM1 incorporates the MAGI- Based Eligibility Group SPA into North Carolina’s State Plan in accordance with the Affordable Care Act. The SPA was approved on December 10, 2013 and the effective date is January 1, 2014.

Enclosed is a copy of the new State Plan pages to be incorporated within a separate section at the back of North Carolina’s approved State Plan:

• S14, Pages S14-1 through S14-6 • S25, Pages S25-1 through S25-3 • S28, Pages S28-1 through S25-6 • S30, Pages S30-1 through S30-5 • S32, Page S32-1 • S33, Page S33-1 • S50, Page S50-1 • S51, Page S51-1 • S52, Page S52-1 through S52-5 • S53, Page S53-1 • S54, Page S54-1 • S55, Page S55-1 • S57, Page S57-1 through S57-2 • S59, Page S59-1 through S59-2

Sandra D. Terrell, MS, R.N. Page 2

In addition, enclosed is a summary of State Plan pages which are superseded by SPA 13-0014-MM1, which should also be incorporated into a separate section in the front of the State Plan:

• Superseding Pages of State Plan Material, 13-0014-MM1

Notwithstanding any other provisions of the North Carolina Medicaid State Plan, the financial eligibility methodologies described in SPA NC 13-0014-MM1 will apply to all MAGI-based eligibility groups covered under North Carolina’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR §435.603 apply to everyone except those individuals described at 42 CFR §435.603(j) for whom MAGI-based methods do not apply. This SPA supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI- based eligibility groups.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Elaine Elmore at 404-562-7408 or Elaine.Elmore@cms.hhs.gov.

Sincerely,

/s/

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

e State/Territory name: North Carolina

e 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-13-001

« Proposed Effective Date

01/01/2014 (mm/dd/yyyy)

« Federal Statute/Regulation Citation

42 CFR Par

« Federal Budget Impact

Federal Fiscal Year Amount

First Year 2014 gl 3931071.0' Second Year 2015 $l 5523155.0!

e Subject of Amendment

Character Count: out of 2000

Medicaid-MAG}Based Bigibility +

=

Lt | J

Governor's Office Review

c Governor's office reported no comment

Cc Comments of Governor's office received

4 =| Lt a

Describe:

Cc No reply received within 45 days of submittal

Ec Other, as specified

Describe:

Character Count: out of 2000

Secretary +

ma

Signature of State Agency Official Submitted By:

Teresa Smith Last Revision Date: Dec 4, 2013

Submit Date:

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: STATE:

13-0014-MM1 North Carolina

Pages or sections of pages being superseded by $25, $28, $30, $51, $52, $53, $54, S57, $59, and $14 and related Pages or sections of pages being deleted as obsolete

State Plan Section Complete Pages Removed Partial Pages Removed Page 2, A.2.b Pagel Page 2, A.2.c Page 2 Page 2a, A.3 Page 3 Page 5, A.10 Page 3a Page 9c,. B.1 for caretaker Page 4 relatives and pregnant Page 4a women Page 12 Page 17c, B.15 Page 13 Page 20, B.14 Page 13a Page 23c, B.20 and B.22 Attachment 2.2-A Page 14 Page 23e, B.25 Page 14a Page 25, C.4 Page 21 Page 23 Page 23b Page 23g Page 23h Supplement 1 to Attachment 2.2-A Page 1 Page 1, A.2.a.(i) & (iii) Page 3b Page 6 related to AFDC Page 11a Recipients, pregnant Page 19 women, infants, and children Page 19a Page 7, 1.a (1)& (2) Attachment 2.6-A Page 19b Page 12, C.1.e. (2) Page 21 Page 18, C.5.e Page 25, 11.a.(3)

Supplement 1 to Attachment 2.6-A Pages 1-4 Supplement 2 to Attachment 2.6-A Pages1-5 Supplement 8a to Attachment 2.6-A Page 1 Page 2, 1° disregard related to AFDC-related groups Page 1a, #3 for AFDC-related h , Supplement 8b to Attachment 2.6-A groups other than medically needy Page 2, #4 Pages 1-3 Supplement 12 to Attachment 2.6-A Addendum

Sep 24, 2013

OMB Control Number 0938-1148 OMB Expiration date: 10, 01

42 CFR 435.110 1902(a)(10)(A GO) 193 1(b) and (d)

im Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state.

The state attests that it operates this eligibility group in accordance with the following provisions: Individuals qualifying under this eligibility group must meet the following criteria:

ml Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included.

The state elects the following options:

This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, C provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training.

(1 Options relating to the definition of caretaker relative (select any that apply): XI Options relating to the definition of dependent child (select the one that applies):

The state elects to eliminate the requirement that a dependent child must be deprived of parental support or @ care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent.

, The child must be deprived of parental support or care, but a less restrictive standard is used to measure ‘“ unemployment of the parent (select the one that applies):

[M] Have household income at or below the standard established by the state.

im MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

[lM] Income standard used for this group [§] Minimum income standard

The minimum income standard used for this group is the state's AFDC payment standard in effect as of May I, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in $14 AFDC Income Standards.

The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment ra) standard.

[8] Maximum income standard

TN No: 13-0014-MM1 Approval Date: 12/10/13 Effective Date: 01/01/14 North Carolina $25-1

Medicaid Eligibility

The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group.

The state's maximum income standard for this eligibility group is:

@ The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, ~ converted to a MAGI-equivalent percent of FPL or amounts by household size.

Cc The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 C demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 C demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

C A percentage of the federal poverty level: %

@ The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The ” standard is described in S14 AFDC Income Standards.

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage C© increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in $14 AFDC Income Standards.

Cc The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in $14 AFDC Income Standards.

C Other dollar amount

[®] Income standard chosen: Indicate the state's income standard used for this eligibility group: @ The minimum income standard C The maximum income standard

The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage © increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards.

© Another income standard in-between the minimum and maximum standards allowed [®] There is no resource test for this eligibility group.

[®] Presumptive Eligibility

TN No: 13-0014-MM1 Approval Date: 12/10/13

Effective Date: 01, North Carolina 525-2 /01/14

Medicaid Eligibility

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

C Yes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: 13-0014-MM1 Approval Date: i Newco Penal ate: 12/10/13 Effective Date: 01/01/14

Enter the AFDC Standards below. All states must enter:

AFDC Payment Standard in Effect As of July 16, 1996

Entry of other standards is optional.

The standard is as follows: @ Statewide standard C Standard varies by region

C Standard varies by living arrangement

C Standard varies in some other way

Standard ($)

434

569

667

744

824

901

417 975

138 1,036

9 1,096

1,169

Ss Medicaid Eligibility

NTE TO EKER A ETUC ERO

MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and

Additional incremental amount

@ Yes

@ No

OMB Control OMB Expirati

Increment amount $ {78

Number 0938-114:

C Yes @ No

The dollar amounts increase automatically each year

TN No: 13-0014-MM1 Approval Date: 12/10/13

North Carolina

$14-1

Effective Date: 01/01/14

The standard is as follows: @ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

Household size | Standard ($)

362

472

544

594

648

698

746

772

812

860

Additional incremental amount @ Yes (No

Increment amount $ |50

The dollar amounts increase automatically each year

C Yes @No

The standard is as follows:

@ Statewide standard

C Standard varies by region

TN No: 13-0014-MM1 North Carolina

Approval Date: 12/10/13 $14-2

Effective Date: 01/01/14

Medicaid Eligibility

© Standard varies by living arrangement

C Standard varies in some other way

Additional incremental amount

Household size | Standard ($) @ Yes CNo — }

429 Increment amount $ |73

562

657

730

807

881

952

Backend

1,001

1,064

10 1,135

The dollar amounts increase automatically each year C Yes (@ No

The standard is as follows:

@ Statewide standard C Standard varies by region

C Standard varies by living arrangement

C: Standard varies in some other way

TN No: 13-0014-MM1

Approval Date: 12/10/13 North Carolina fel

Effective Date: 01/01/14 $14-3

Medicaid Eligibility

Household size | Standard ($)

Ee 362 fr |2 472

Ei

:

13 544 hal 594 E +15 648

698 746 772 812 860

Additional incremental amount @ Yes (No

Increment amount $ |50

C Yes @No

The dollar amounts increase automatically each year

The standard is as follows:

C Statewide standard © Standard varies by region © Standard varies by living arrangement

© Standard varies in some other way

C Yes ONo

The dollar amounts increase automatically each year

TN No: 13-0014-MM1 Approval Date: 12/10/13

North Carolina

$14-4

Effective Date: 01/01/14

The standard is as follows: C Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year

C Yes C No

The standard is as follows:

C Statewide standard C Standard varies by region © Standard varies by living arrangement

© Standard varies in some other way

The dollar amounts increase automatically each year

C Yes CNo

The standard is as follows:

C Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

The dollar amounts increase automatically each year

© Yes ONo

TN No: 13-0014-MM1 Approval Date: 12/10/13 North Carolina S14-5

Effective Date: 01/01/14

Medicaid Eligibility

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN No: 13-0014-MM1 North Carolina Approval Date: 12/10/13

eaae Effective Nas..n- sn. -

Medicaid Eligibility

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

42 CFR 435.116

1902(a)(10)(A)(4)(HIT) and (IV) 1902(a)(10)(A)(ii)(1), (IV) and (IX) 1931(b) and (d)

1920

Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. y The state attests that it operates this eligibility group in accordance with the following provisions: [MW Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4.

Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110.

@ Yes © No

wl MAGI-based income methodologies are used in calculating household income. Please refer as necessary to $10 MAGI-Based Income Methodologies, completed by the state.

[im] Income standard used for this group [®] Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.)

The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so.

C Yes @No The minimum income standard for this eligibility group is 133% FPL.

[®) Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group.

The state's maximum income standard for this eligibility group is:

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IID) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- @ related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) ” (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV)

(institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

N No: 13-0014-MM1 Approval Date: 12/10, e 4 : 13 ffecti vol ‘ /10/ Effective Date: 01/01/1

Medicaid Eligibility

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(IID) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), |902(a)(10)

© (A)(ii)() (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as ~” of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

0 The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as ~ of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C 185% FPL

The amount of the maximum income standard is:|196 % FPL

[i] Income standard chosen Indicate the state's income standard used for this eligibility group: C The minimum income standard @ The maximum income standard C© Another income standard in-between the minimum and maximum standards allowed. [@] There is no resource test for this eligibility group. [B] Benefits for individuals in this eligibility group consist of the following: © All pregnant women eligible under this group receive full Medicaid coverage under this state plan.

e Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive ~ only pregnancy-related services.

Pregnancy-related services, as defined at 42 CFR 440.210 (a)(2), include prenatal, delivery, postpartum and family planning services, as well as services related to conditions which may complicate pregnancy.

Full Medicaid coverage is provided only for pregnant women with income at or below the income limit described below:

[@] Minimum income limit for full Medicaid coverage

The minimum income standard used for full coverage under this group is the state's AFDC payment standard in effect as of May |, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards.

The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard.

[&] Maximum income limit for full Medicaid coverage

TN No: 13-0014-MM1 Approval Date: 12/10/13

Effective Date: North Carolina S7R2.9 e Date: 01/01/14

Medicaid Eligibility

The highest effective income level for coverage under section 1902(a)(10)(A)(i)(III) (qualified pregnant (@ women) or section 1931(b) and (d) (low-income families) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent standard.

The highest effective income level for coverage under section 1902(a)(10)(A)(i)(III) (qualified pregnant C women) or section 1931(b) and (d) (low-income families) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent standard.

The state's effective income level for any population of pregnant women under a Medicaid 1115 “ demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

. The state's effective income level for any population of pregnant women under a Medicaid 1115 “ demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

The amount of the maximum income limit for full Medicaid coverage is:

C A percentage of the federal poverty level: %

@ A dollar amount

The standard is as follows:

@ Statewide standard C Standard varies by region

C Standard varies by living arrangement

© Standard varies in some other way

0: 13-0014- 1 App ‘oval Date 12/10, ective D; 4 TNN 4-MM te: i

Medicaid Eligibility

Additional incremental amount

Household size} Standard ($) @Yes CNo

434

Increment amount $ |78

569

667

744

824

901

975

1,036

1,096

1,169

The dollar amounts increase automatically each year

© Yes @No

[lM] Income limit chosen for full Medicaid coverage: @ The minimum income limit © The maximum income limit C Another income limit in-between the minimum and maximum standards allowed. [mi] Presumptive Eligibility

The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity.

@ Yes (No [H] The presumptive period begins on the date the determination is made.

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

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

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

TN No: 13-0014-MM1 Approval Date: 12/10/13

North Carolina 528-4 Effective Date: 01/01/14

Medicaid Eligibility

[m] There may be no more than one period of presumptive eligibility per pregnancy. A written application must be signed by the applicant or representative. @ Yes © No C The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

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

{@] The presumptive eligibility determination is based on the following factors: [m] The woman must be pregnant [M] Household income must not exceed the applicable income standard at 42 CFR 435.116. [KI State residency

[K] Citizenship, status as a national, or satisfactory immigration status

aw The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group.

| A qualified entity is an entity that is determined by the agency to be capable of making presumptive _ eligibility determinations based on an individual’s household income and other requirements, and that | meets at least one of the following requirements. Select one or more of the following types of entities

| used to determine presumptive eligibility for this eligibility group:

i= Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan

oO Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act

oO Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental (J Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

oO Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP)

oO Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

(J Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs (1 Is a state or Tribal child support enforcement agency under title IV-D of the Act

oO Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

TN No: 13-0014-MM1 Approval Date: 12/10/13

Effective Date: 01/01/14 North Carolina $28-5 jou

Medicaid Eligibility

oO Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act

Is an organization that determines eligibility for any assistance or benefits provided under any program

oO of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

X Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization

(] Other entity the agency determines is capable of making presumptive eligibility determinations:

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: 13-0014-MM1

Approval Date: 12/10, North Carolina /10/13

Effective Date: 528-6 Ive Date: 01/01/14

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expirati 2 10/.

42 CFR 435.118

1902(a)(10)(A)(i)(II1), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d)

a Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group.

The state attests that it operates this eligibility group in accordance with the following provisions:

{@) Children qualifying under this eligibility group must meet the following criteria: [mM] Are under age 19 [m) Have household income at or below the standard established by the state.

im MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

[®] Income standard used for infants under age one

[) Minimum income standard

The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so.

C Yes @No

The minimum income standard for infants under age one is 133% FPL.

[®] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAG]-equivalent standards and the determination of the maximum income standard to be used for infants under age one.

The state's maximum income standard for this age group is:

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)C11) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related

@ infants), 1902(a)(10)(A)(ii)(TX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

TN No: 13-0014-MM1 Approval Date: 12/10/13 Effective Date: 01/01/14

Narth Carnlina c2n.1

Medicaid Eligibility

The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related

© infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(TV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted toa MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of infants under age one under a Medicaid 1115 ~ demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C 185% FPL

Enter the amount of the maximum income standard: |210 % FPL

{™] Income standard chosen The state's income standard used for infants under age one is:

@ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)

© (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(EX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)('V) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

, Another income standard in-between the minimum and maximum standards allowed, provided it is higher than “ the effective income standard for this age group in the state plan as of March 23, 2010.

{| Income standard for children age one through age five, inclusive

[=] Minimum income standard

TN No: 13-0014-MM1 Approval Date: 12/10/13 Effective Date: 01/01/14

ALeeth Carvrenlinn cans

Medicaid Eligibility

The minimum income standard used for this age group is 133% FPL. [=] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five.

The state's maximum income standard for children age one through five is:

The state's highest effective income level for coverage of children age one through five under sections 1931 (low-

@ income families), 1902(a)(10)(A)(i)(IIL) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's highest effective income level for coverage of children age one through five under sections 1931 (low- C income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- * related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of children age one through five under a Medicaid 1115 ~ demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. .

C The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Enter the amount of the maximum income standard: |210 % FPL

{™_ Income standard chosen The state's income standard used for children age one through five is: @ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children),

C 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(II) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

TN No: 13-0014-MM1 . Nosh pein Approval Date: 12/10/13 Effective Date: 01/01/14

Medicaid Eligibility

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children

’ age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and _ if not chosen as the maximum income standard, the state's effective income level for any population of children " age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL.

. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than ~ the effective income standard for this age group in the state plan as of March 23, 2010. [®] Income standard for children age six through age eighteen, inclusive [8] Minimum income standard The minimum income standard used for this age group is 133% FPL.

[) Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen.

The state's maximum income standard for children age six through eighteen is:

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 C (low-income families), 1902(a)(10)(A)(i)(II) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty “ level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's highest effective income level for coverage of children age six through eighteen under sections 1931 Oo (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VIL) (mandatory poverty ~ Jevel-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

fo) The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 ~~ demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

fa} The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 ~” demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

@ 133% FPL

[mM] Income standard chosen

The state's income standard used for children age six through eighteen is:

TN No: 13-0014-MM1 ; North Carnie Approval Date: 12/10/13 Effective Date: 01/01/14

CCMS Medicaid Eligibility

@ The maximum income standard

If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children),

CG 1902(a)(10)(A)(i)(VID) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children Cc age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), ~’ 1902(a)(10)(A)(i)(VID) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL.

If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL.

, Another income standard in-between the minimum and maximum standards allowed, provided it is higher than “ the effective income standard for this age group in the state plan as of March 23, 2010.

{| There is no resource test for this eligibility group. (] Presumptive Eligibility The state covers children when determined presumptively eligible by a qualified entity.

C Yes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: 13-0014-MM1 Approval Date: 12/10/13 Effective Date: 01/01/14

Medicaid Eligibility

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

1902(a)(10)(A)(i)( VI) 42 CFR 435.119

The state covers the Adult Group as described at 42 CFR 435.119. C Yes @ No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: 13-0014-MM1 Approval Date: 12/10/13 Effective Date: 01/01/14 North Carolina $32-1

Medicaid Eligibility

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

7 4 4 ‘|

42 CFR 435.150 1902(a)(10)(A)(i)(IX)

i Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care.

The state attests that it operates this eligibility group under the following provisions: [M Individuals qualifying under this eligibility group must meet the following criteria: (m) Are under age 26.

am Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group.

Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state

[® plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program.

The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system.

CyYes @No

The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures

it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible.

CYes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN No: 13-0014-MM1

Approval Date: ; North Carolina nen ate: 12/10/13 Effective Date: 01/01/14

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

1902(a)(10)(A)(i)(XX) 1902(bh) 42 CFR 435.218

Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218.

C Yes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: 13-0014-MM1 Approval Date: 12/10/13 Effective Date: 01/01/14 North Carolina $50-1

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

42 CFR 435.220 1902(a)(10)(A)(ii)(1)

Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other

caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220.

C Yes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN No: 13-0014-MM1

Approval Date: . North Carolina Pproval ate: 12/10/13 Effective Date: 01/01/14

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

42 CFR 435.222 1902(a)(10)(A)(ii)(1) 1902(a)(10)(A)i\(TV)

Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222.

@ Yes (No

The state attests that it operates this eligibility group in accordance with the following provisions:

wl Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria:

[M] Be under age 21, or a lower age, as defined within the reasonable classification.

iw Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification.

[Ml] Not be eligible and enrolled for mandatory coverage under the state plan.

mw MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age.

@ Yes © No

The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age.

@ Yes (No ion: red i dicai as of h

a The state attaches the approved pages from the Medicaid state plan as of March 23, 2010 to indicate the age groups, reasonable classifications, and income standards used at that time for this eligibility group.

nt Cov of All Children under a ified A\

TN No: 13-0014-MM1 Approval Date: 12/10/13 Effective Date: 01/01/14 North Carolina eoz4

Medicaid Eligibility

The state's effective income level for this classification of children under a Medicaid 1115 © Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

The state's effective income level for this classification of children under a Medicaid 1115 © Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

Enter the amount of the maximum income standard:

© A percentage of the federal poverty level: %

The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- C equivalent standard. This standard is described in S14 AFDC Income Standards, This option “should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is © described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group.

@ Other dollar amount

The standard is as follows:

@ Statewide standard C Standard varies by region C Standard varies by living arrangement

C Standard varies in some other way

TN No: 13-0014-MM1 Approval Date: 12/10/13 Effective Date: 01/01/14

Alnavek C.

COTTER TOR MEERA A

ME NCAND RMER

Medicaid Eligibility

Additional incremental amount

Household size | Standard ($) @ Yes CNo

434

Increment amount $ |78

569

667

744

824

901

975

1,036

1,096

1,169

The dollar amounts increase automatically each year © Yes @No

[®] Income standard chosen

Individuals qualify under this classification under the following income standard:

The minimum standard. The maximum income standard.

If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size.

TN No: 13-0014-MM1

North C.

‘aroling

Approval Date: 12/10/13

Pra a

Effective Date: 01/01/14

Medicaid Eligibility

If not chosen as the maximum income standard, and if higher than the effective income level used C under the Medicaid state plan as of March 23, 2010, the state's effective income level for this ~ classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size.

Another income standard in-between the minimum and maximum standards allowed, provided it is C higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent.

urrel veri f le ification: red in the Medicaid State Plan f March 23, 201

The state covers reasonable classifications of children previously covered in the Medicaid state plan as of March 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/or income standard for this classification covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income.

C Yes @ No Other Reasonable Classifications Previously Covered

The state covers reasonable classifications of children not covered in the Medicaid state plan as of March 23, 2010, but covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age group.

© Yes @No Additional new age groups or reasonable classifications covered

If the state has not elected to cover the Adult Group (42 CFR 435.119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage.

The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted to a MAGI-equivalent standard.

© Yes @No

[M] There is no resource test for this eligibility group.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: 13-0014-MM1 Approval Date: 12/10/13

Effecti : North Carolina coo c ctive Date: 01/01/14

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

42 CER 435.227 1902(a)(10)(A)(ii)( VIL)

Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non 1V-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227.

© No The state attests that it operates this eligibility group in accordance with the following provisions: [®] Individuals qualifying under this eligibility group must meet the following criteria:

aw The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care;

[@ Are under the following age (see the Guidance for restrictions on the selection of an age): © Under age 21 C© Under age 20 © Under age 19 @ Under age 18

aw MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes ©No

The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. @ Yes ©No

iw Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement.

The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan

as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

© Yes @No

[M] There is no resource test for this eligibility group.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN No: 13-0014-MM1 A Pproval Date: . North Carolina ec24 @: 12/10/13 Effective Date: 01/01/14

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

1902(a)(10)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B)

Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435,229.

C Yes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: 13-0014-MM1 Approval Date: 12/10/13 Effective Date: 01/01/14 North Carolina $54-1

Medicaid Eligibility

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

1902(a)(10)(A)(ii)(XID) 1902(z)

Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services.

C Yes @ No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: 13-0014-MM1 Approval Date: 12/10/13

Effective Date: North Carolina $55-1 ive Date: 01/01/14

Medicaid Eligibility

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

42. CER 435.226 1902(a)(10)(A)(ii)(XVIL)

Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226.

@ Yes CNo The state attests that it operates this eligibility group in accordance with the following provisions: {] Individuals qualifying under this eligibility group must meet the following criteria:

{M] Are under the following age ©@ Under age 21 © Under age 20 © Under age 19

[M] Were in foster care under the responsibility of a state on their 18th birthday.

[m] Are not eligible and enrolled for mandatory coverage under the Medicaid state plan.

[®] Have household income at or below a standard established by the state.

il MAGI-based income methodologies are used in calculating household income. Please refer as necessary to $10 MAGI- Based Income Methodologies, completed by the state.

The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013.

@ Yes ONo

The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. @ Yes CNo

The state covers children under this eligibility group, as follows (selection may not be more restrictive than the coverage in the Medicaid state plan as of March 23, 2010 until October 1, 2019, nor more liberal than the most

Cy liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013):

@ All children under the age selected © A reasonable classification of children under the age selected:

[m] Income standard used for this eligibility group

[| Minimum income standard

The minimum income standard for this classification of children is the AFDC payment standard in effect

as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards.

TN No: 13-0014-MM1 Approval Date: 12/10/13 i neanaein torn / Effective Date: 01/01/14

Medicaid Eligibility

[M) Maximum income standard

No income test was used (all income was disregarded) for this eligibility group either in the

Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013.

@ Yes CONo

mw No income test was used (all income was disregarded) for this eligibility group under (check all that apply):

IK] The Medicaid state plan as of March 23, 2010.

[KX] The Medicaid state plan as of December 31, 2013.

(1) A Medicaid 1115 demonstration as of March 23, 2010. (A Medicaid 1115 demonstration as of December 31, 2013.

The state's maximum standard for this eligibility group is no income test (all income is disregarded).

{m] Income standard chosen Individuals qualify under this eligibility group under the following income standard:

This eligibility group does not use an income test (all income is disregarded).

[BM] There is no resource test for this eligibility group.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN No: 13-0014-MM1

Approval Date: 12/10/13 i : Noth ewe mova /10/ Effective Date: 01/01/14

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

1902(a)(10)(A)(i(XX1) 42 CFR 435.214

Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214.

@ Yes (|No

The state attests that it operates this eligibility group in accordance with the following provisions: [M] The individual may be a male or a female. [] Income standard used for this group

[B] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for this eligibility group.

The state's maximum income standard for this eligibility group is the highest of the following:

> The state's current effective income level for the Pregnant Women eligibility group (42 CFR 435.116) under the ~ Medicaid state plan.

© The state's current effective income level for pregnant women under a Medicaid 1115 demonstration. © The state's current effective income level for Targeted Low-Income Pregnant Women under the CHIP state plan.

C© The state's current effective income level for pregnant women under a CHIP 1115 demonstration.

The amount of the maximum income standard is:| 196 % FPL

[M] Income standard chosen The state's income standard used for this eligibility group is: C The maximum income standard

@ Another income standard less than the maximum standard allowed.

The amount of the income standard is: ]195 % FPL

mw MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

TN No: 13-0014-MM1 Approval Date: 12/10/13 Effective Date: 01/01/14 North Carolina $59-1

Medicaid Eligibility

[M] In determining eligibility for this group, the state uses the following household size: All of the members of the family are included in the household (Only the applicant is included in the household ( The state increases the household size by one [my In determining eligibility for this group, the state uses the following income methodology:

> The state considers the income of the applicant and all legally responsible household members ~ (using MAGI-based methodology).

© The state considers only the income of the applicant. [Ml Benefits for this eligibility group are limited to family planning and related services described in the Benefit section. [M) Presumptive Eligibility

The state makes family planning services and supplies available to individuals covered under this group when determined presumptively eligible by a qualified entity.

C Yes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

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

TN No: 13-0014-MM1

Approval Date: 12/10/13 Effecti : Nowth cream ective Date: 01/01/14

§59-2

Table of Contents State/Territory Name: North Carolina State Plan Amendment (SPA) #: 13-0015-MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

December 20, 2013

Ms. Sandra D. Terrell, M.S., R.N. Acting Director Division of Medical Assistance North Carolina Department of Health and Human Services 2501 Mail Service Center Raleigh, North Carolina 27699-2501

Attention: Teresa Smith

RE: North Carolina Title XIX State Plan Amendment, Transmittal # NC 13-0015-MM3

Dear Ms. Terrell:

Enclosed is an approved copy of North Carolina’s state plan amendment (SPA) 13-0015-MM3, which was submitted to CMS on October 4, 2013. SPA 13-0015-MM3 incorporates the MAGI-Based Income Methodologies into North Carolina’s state plan in accordance with the Affordable Care Act. This SPA was approved on December 19, 2013. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages to be incorporated within a separate section at the back of North Carolina’s approved state plan:

• S10, Pages S10-1 and S10-2

In addition, enclosed is a summary of state plan pages which are superseded by SPA 13-0015-MM3, which should also be incorporated into a separate section in the front of the state plan:

• Superseding Pages of State Plan Material, 13-0015-MM3

Notwithstanding any other provisions of the North Carolina Medicaid state plan, the financial eligibility methodologies described in SPA NC-13-0015-MM3 will apply to all MAGI-based eligibility groups covered under North Carolina’s Medicaid state plan. The MAGI financial methodologies set forth in 42 CFR §435.603 apply to everyone except those individuals described at 42 CFR §435.603(j) for whom MAGI-based methods do not apply. This SPA supersedes the current financial eligibility provisions of the Medicaid state plan only with respect to the MAGI- based eligibility groups.

Ms. Sandra D. Terrell, M.S., R.N. Page 2

Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Elaine Elmore at 404-562-7408 or Elaine.Elmore@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: North Carolina

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-13-001

Proposed Effective Date

01/01/2014

[

(mm/dd/yyyy)

Federal Statute/Regulation Citation

| 1902(e)(14

Federal Budget Impact

Federal Fiscal Year Amount

First Year | 2014 gl 0.00 Second Year | 2015 gl 0.00

Subject of Amendment

Character count out of 2000

$10 -- MAGBased Income Met 4

Li re

Governor's Office Review

c Governor's office reported no comment

c Comments of Governor's office received

5 Am —

c No reply received within 45 days of submittal

Describe:

E Other, as specified

Describe:

Character count out of 2000

Secretary +

fal Ls | ma

Signature of State Agency Official Submitted By:

Teresa Smith Last Revision Date: Dec 17, 2013

Submit Date:

Oct 4, 2013

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: 13-0015-MM3

STATE: North Carolina

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S10 - MAGI Income Methodology

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

Notwithstanding any other provisions of the North Carolina Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment 13-0015-MM3 will apply to all MAGI-based eligibility groups covered under North Carolina’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

Medicaid Eligibility

OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 er 5

1902(e)(14) 42 CFR 435.603

i The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603.

In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid 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 application of such methods results in a determination of ineligibility prior to such date.

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 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:

(@ Current monthly household income and family size

C Projected annual household income and family size for the remaining months of the current calendar year

In determining current monthly or projected annual household income, the state will use reasonable methods to: (7 Include a prorated portion of a 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 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.

In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d).

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.

C Yes (@No

TN No: 13-0015-MM3 Approval Date: 12/19/13 Effective Date: 01/01/14 North Carolina $10-1

ee es CMS Medicaid Eligibility

COONS TOR EDTA h IONS NEEICES

[ll] The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is:

@ Age 19

C Age 19, or in the case of full-time students, age 21

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

N i A Da / Effective Date: 01/01/1

Table of Contents State/Territory Name: North Carolina State Plan Amendment (SPA) #: 13-0017-MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

December 20, 2013

Ms. Sandra D. Terrell, M.S., R.N. Acting Director Division of Medical Assistance North Carolina Department of Health and Human Services 2501 Mail Service Center Raleigh, North Carolina 27699-2501

Attention: Teresa Smith

RE: North Carolina Title XIX State Plan Amendment, Transmittal # NC 13-0017-MM6

Dear Ms. Terrell:

Enclosed is an approved copy of North Carolina’s state plan amendment (SPA) 13-0017-MM6, which was submitted to CMS on October 4, 2013. SPA 13-0017-MM6 incorporates the citizenship regulations, specifies reasonable opportunity period options, and specifies policy options related to eligible non-citizens into North Carolina’s state plan in accordance with the Social Security Act and regulations at 42 CFR Part 435. This SPA was approved on December 19, 2013. The effective date of the SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages to be incorporated within a separate section at the back of North Carolina’s approved state plan:

• S89, Pages S10-1 through S10-3

Also enclosed are the revised state plan pages removing sections that have been superseded through NC 13-0017-MM6.

Congratulations to you and your staff for your hard work and strong collaboration. If you have any questions, please contact Elaine Elmore at 404-562-7408 or Elaine.Elmore@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: North Carolina

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-13-001

Proposed Effective Date

| 01/01/2014 (mm/dd/yyyy)

Federal Statute/Regulation Citation

| 19029e)(1«

Federal Budget Impact

Federal Fiscal Year Amount

First Year

gl 0.00

Second Year

—

2015

gl 0.00

Subject of Amendment

Character count out of 2000

Citizenship and Non-citizen Bigi 4

Ll J ma

Governor's Office Review

c Governor's office reported no comment

Cc Comments of Governor's office received

5 oe ae

Describe:

C No reply received within 45 days of submittal

E Other, as specified

Describe:

Character Count: out of 2000

Secretary +

Lt J | Signature of State Agency Official Submitted By:

Teresa Smith Last Revision Date: Dec 19, 2013

Submit Date:

Oct 4, 2013

Revision: HCFA-PM-914 (BPD) ATTACHMENT 2.6-A AUGUST 1991 Page 2 OMB No.: 0938-

State: North Carolina

Citation(s) Condition or Requirement

b. For the medically needy, meets the non- financial eligibility conditions of 42 CFR Part 435.

1905(p) of the c. For financially eligible qualified

Act Medicare beneficiaries covered under section 1902(a)(10)(E)(i) of the Act, meets the non-financial criteria of section 1905(p) of the Act.

1905(s) of the d. For financially eligible qualified

Act disabled and working individuals covered under section 1902(a)(10)(E)(ii) of the Act, meets the non- financial criteria of section 1905(s).

TN No.13-0017-MM-6 Supersedes Approval Date: 12-19-13 Effective Date 01/01/2014 TN No. 10-012

Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 2.6-A

AUGUST 1991 Page 3 OMB No.: 0938- State: North Carolina Citation Condition or Requirement 42 CFR 435.403 4. Is a resident of the State, regardless of whether or not the 1902(b) of the Act individual maintains the residence permanently or

maintains it at a fixed address.

Xx State has interstate residency agreement with the following States:

Georgia State has open agreement(s).

Not applicable; no residency requirement.

TN No. 13-0017-MM-6 Supersedes Approval Date 12-19-13 Effective Date 01/01/2014 TN No. 92-01 HCFA ID: 7985E

Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 2.6-A AUGUST 1991 Page 3.1 OMB No.: 0938-

State: North Carolina

Citation Condition or Requirement

INTENTIONALLY LEFT BLANK

TN No. 13-0017-MM-6 Supersedes Approval Date: 12-19-13 Effective Date 01/01/2014

TN No. 10-012

Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 2.6-A AUGUST 1991 Page 3.2 OMB No.: 0938-

State: North Carolina

Citation Condition or Requirement

INTENTIONALLY LEFT BLANK

TN No. 13-0017-MM-6 Supersedes Approval Date: 12-19-13 Effective Date 01/01/2014 TN No. 10-012

Medicaid Eligibility

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

1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4)

42 CFR 435.4

42 CFR 435.406

42 CFR 435,956

Citizenship and Non-Citizen Eligibility

The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status.

{m] The state provides Medicaid eligibility to otherwise eligible individuals: {) Who are citizens or nationals of the United States; and

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

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory

rh immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

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

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process.

C Yes @No

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

@ Yes CNo 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 containing the declaration of citizenship or immigration status.

TN No: 13-0017-MM6 Approval Date: 12/19/13 Effective Date: 01/01/14 North Carolina $89-1

Medicaid Eligibility

The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613).

@ Yes CNo

The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act.

@ Yes (No X] Pregnant women &) Individuals under age 21: C Individuals under age 21 C Individuals under age 20 @ Individuals under age 19

cH An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan.

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

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

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

im 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;

Granted employment authorization under 8 CFR 274a.12(c); Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; Under Deferred Enforced Departure (DED) in accordance with a decision made by the President;

Granted Deferred Action status;

CCC Te

Granted an administrative stay of removal under 8 CFR 241; {) Beneficiary of approved visa petition who has a pending application for adjustment of status;

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

[®) Has been granted employment authorization; or

{M] Is under the age of 14 and has had an application pending for at least 180 days;

TN No: 13-0017-MM6 Approval Date: 12/19/13 Effective Date: 01/01/14 North Carolina S$89-2

Medicaid Eligibility

6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b));

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.

( Other

The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following

individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN:

[™] Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613;

iw Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: 13-0017-MM6 Approval Date: 12/19/13 Effective Date: 01/01/14

Alarth Caralina coo 2

Table of Contents State/Territory Name: North Carolina State Plan Amendment (SPA)#: 14-001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303 CMS CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS June 9, 2014 Ms. Sandra D. Terrell, MS, R.N. Chief Operating Officer Division ofMedical Assistance North Carolina Department of Health and Human Services 2501 Mail Service Center Raleigh, North Carolina 27699-2501 Attention: Teresa Smith RE: North Carolina Title XIX State Plan Amendment, Transmittal # NC 14-001 Dear Ms. Terrell: We reviewed the proposed amendment to the North Carolina Medicaid State Plan Amendment (SPA) NC 14-001 that was received in the Regional Office on March 19, 2014. The amendment removes coverage for the family planning optional eligibility group from the Medicaid state plan. As noted in the approved paper-based 179 transmittal for TN No. 14-001, the amendment removes paper-based pages Attachment 2.2-A page 23g and Attachment 3.1-A page 9 from the state plan. As noted in the MMDL-based 179 for TN No. 14-0001-MMl, the SPA also amends the MAGI- based family planning PDF S59 to remove the state's election of this eligibility group. Based on the information provided, we are now ready to approve the Medicaid State Plan Amendment NC 14-001. This SPA was approved on June 6, 2014. The effective date of this amendment is January 1, 2014. We are enclosing the signed paper-based HCFA-179, the MMDL-based 179, and the approved plan pages. If you have any questions or need any further assistance, please contact Elaine Elmore at ( 404) 562-7 408. Sincerely, //s// Jackie Glaze Associate Regional Administrator Division ofMedicaid & Children's Health Operations Enclosures cc: Aldona Z. Wos, M.D., Secretary North Carolina Department of Health and Human Services Robin G. Cummings, M.D.

DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER: 14-001 3. PROGRAM IDENTIFICATION: FORM APPROVED OMB NO. 0938-0193 2. STATE NC FOR: HEALTH CARE FINANCING ADMINISTRATION TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 4. PROPOSED EFFECTIVE DATE May 1, 2014 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN C8J AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: Section 2303 of the Affordable Care Act (ACA) 7. FEDERAL BUDGET IMPACT: a. FFY 14 b. FFY 15 $0.00 $0.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR A IT ACHMENT (/f Applicable): Attachment 3.1-A, Page 9; Attachment 2.2-A, Page 23g Attachment 3.1-A, Page 9; Attachment 2.2-A, Page 23g I 0. SUBJECT OF AMENDMENT: Family Planning Services One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL C8J OTHER, AS SPECIFIED: Secretary 16. RETURN TO: 12. SIGNATURE OF STATE AGENCY OFFICIAL: /lsi! Office of the Secretary t-:-:-=:-::-==~--:-:-------------------1 Department of Health and Human Services 13. TYPED NAME: S · C 2001 Mail , erv1ce ~enter Aldona Z. M.D. t--14-_-T.....,IT ...... L_E_:_S_ec-'-·re-t-ar-y---------------------1 Raleigh, NC 27699-200.14 15. DATE SUBMITTED: FORM HCFA-179 (07-92)

Citation TN. No. 14-001 Supersedes TN. No. 13-004 State{ferritory: North Carolina ATTACHMENT 3.1-A Page9 OMBNO.: INTENTIONALLY LEFT BLANK Approval Date: 06-06-14 Effective Date: 01/01/2014

Revision: Citation TN. No. Supersedes TN. No. 13-004 CMS-PM- State{ferritory: North Carolina Groups Covered ATTACHMENT 2.2-A Page 23g OMB No.: INTENTIONALLY LEFT BLANK Approval Date:06-06-14 Effective Date: QlLOl/2014

MEDICAL ASSISTANCE State: NORTH CAROLINA Attachment 4.19-8 Section 4, Page 3 PAYMENTS FOR MEDICAL AND REMEDIAL CARE AND SERVICE 4.c. Family Planning Services Payments for Family Planning services covered under Attachment 3.1-A.l are equal to the lower of the submitted charge or the appropriate fee from the North Carolina Medicaid Family Planning Services Fee Schedule. All rates are published on the website at http://www.ncdhhs.gov/dma/fce/indcx.ht@. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers. The agency's fee schedule rates were set as of July l, 2013 and arc effective for services provided on or after that date. (a) Family Planning services are reimbursed at 100 percent of the Medicaid Physician Schedule in effect on July 1, 2013. (b) Family Planning services provided by Local Health Departments (governmental agencies) are paid at cost and will be cost settled as described in Attachment 4.19-8, Section 9, page 1 of the state plan. TN. No. 14-001 Supersedes TN. No. 92-18 Approval Date: 06-06-14 Eff. Date: 01/01/2014

Medicaid Eligibility OMB Control Number 0938-1148 OMB date: 10/31/2014 Individuals Eligible for Family Planning Services -The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. r Yes (e' No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN No. 14-0001-MM1 North Carolina Approval Date: 06/06/14 559 Effective Date: 01/01/14

Table of Contents

State/Territory Name: North Carolina State Plan Amendment (SPA) #:14-0003-MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, GA 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

December 2, 2014

Sandra D. Terrell, M.S., R.N. Chief Operating Officer Division of Medical Assistance North Carolina Department of Health and Human Services 2501 Mail Service Center Raleigh, NC 27699-2501

Attention: Teresa Smith

RE: North Carolina State Plan Amendment, Transmittal #14-0003-MM7

Dear Ms. Terrell:

Enclosed is an approved copy of North Carolina’s state plan amendment (SPA) 14-0003-MM7, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 4, 2014. SPA 14-0003-MM7 establishes that one or more qualified hospitals are determining presumptive eligibility, and that the state is providing coverage for individuals determined presumptively eligible, in accordance with the Affordable Care Act. The SPA was approved on December 1, 2014. The effective date of this SPA is January 1, 2014.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the back of North Carolina’s approved state plan, as well as a summary of the state plan pages which are superseded by SPA 14-0003-MM7, which should be incorporated into a separate section in the front of the state plan.

CMS appreciates the significant amount of work your staff dedicated to preparing and completing this state plan amendment. If you have any questions concerning this SPA, please contact Elaine Elmore, at either 404-562-7408 or by email at Elaine.Elmore@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

ccs: Aldona Z. Wos, M.D., Secretary NCDHHS Robin G. Cummings, M.D., Director

Medicaid State Plan Eligibility: Summary Page (CMS 179) • State/Territory name: North Carolina • 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-14-000 • Proposed Effective Date 01/01/2014(mm/dd/yyyy) • Federal Statute/Regulation Citation 42 CFR 435 • Federal Budget Impact Federal Fiscal Year Amount First Year 2014

$ 13557275.0 Second Year 2015

$ 18582301.0 • Subject of Amendment Character Count: out of 2000

Hospital Presumptive Eligibility

• Governor's Office Review o Governor's office reported no comment o Comments of Governor's office received Describe:

o No reply received within 45 days of submittal o Other, as specified Describe: Character Count: out of 2000 Department of Health & Human S

• Signature of State Agency Official o Submitted By: Pamela Beatty o Last Revision Date: Dec 1, 2014 o o Submit Date: Mar 31, 2014 o

Medicaid Eligibility

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

42 CFR 435.1110

coverage for individuals determined presumptively eligible under this provision.

@Yes (No

(One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid

The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: [I A qualified hospital is a hospital that:

[Wits election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures.

Medicaid agency.

@yYes (No {Ml The eligibility groups or populations for which hospitals determine eligibility presumptively are: (@) Pregnant Women [m] Infants and Children under Age 19 [ Parents and Other Caretaker Relatives {@) Adult Group, if covered by the state (M] Individuals above 133% FPL under Age 65, if covered by the state [@ Individuals Eligible for Family Planning Services, if covered by the state (@) Former Foster Care Children (®) Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state (DJ Other Family/Adult groups: CD Eligibility groups for individuals age 65 and over C0 Eligibility groups for individuals who are blind CD Eligibility groups for individuals with disabilities (CD Other Medicaid state plan eligibility groups

C Demonstration populations covered under section 1115

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

Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of

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

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

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Medicaid Eligibility

@yYes CNo

Select one or both:

rx The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period.

The State will require a threshold of 95% for full Medicaid applications submitted by individuals determined presumptively eligible by a hospital. Hospitals cannot serve as the applicants’ authorized representative on either a presumptive or regular Medicaid eligibility application during the presumptive period. Hospital providers shall participate in Department-approved training on North Carolina policies and procedures. The Department shall disqualify a hospital from conducting presumptive eligibility determination if, within six consecutive months of qualifying or for any subsequent rolling six month period, the hospital does not make presumptive eligibility determinations in accordance with North Carolina policies and procedures Description of standards: }and federal laws and regulations or does not meet the standards set forth in this State Plan and does not improve its performance in meeting the standards within three months of completing an additional training and implementing a Department-approved corrective action plan, if required. ‘A hospital disqualified from conducting presumptive eligibility determinations shall not be eligible to reapply as a qualified hospital unless the hospital has a change of ownership as defined in G.S. 108C-10(a). A qualified hospital shall report a change of ownership or any change in the staff authorized to conduct presumptive eligibility to the Provider Services section of the Department of Health and Human Services, Division of Medical Assistance.

R The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period.

The State will require that 95% of individuals who are determined eligible for presumptive eligibility and who submit a regular Medicaid application will be determined eligible for Medicaid. The Department shall disqualify a hospital from conducting presumptive eligibility determination if, within six consecutive months of qualifying or for any subsequent rolling six month period, the hospital does not make presumptive eligibility determinations in accordance with North Carolina policies and procedures and federal laws and regulations or does not meet the standards set forth in this State Plan and does not improve its performance in meeting the standards within three months of completing an additional training and implementing a Department-approved corrective action plan, if required. A hospital disqualified from conducting presumptive eligibility determinations shall! not be eligible to reapply as a qualified hospital unless the hospital has a change of ownership as defined in G.S, 108C-{0(a). A qualified hospital shall report a change of ownership or any change in the staff authorized to conduct presumptive eligibility to the Provider Services section of the Department of Health and Human Services, Division of Medical Assistance.

Description of standards:

[mw] The presumptive period begins on the date the determination is made. [i] The end date of the presumptive period is the earlier of:

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

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

[@ Periods of presumptive eligibility are limited as follows:

TN NO: 14-003-MM7 Approval Date: 12-01-14 Effective Date: 01-01-14 North Carolina §21-2 Page 2 of 3

Medicaid Eligibility

(No more than one period within a calendar year. C No more than one period within two calendar years.

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

(© Other reasonable limitation:

Name of limitation Description Limitation based on the No more than one period within 24 months of the uses presumptive eligibility date. date of the presumptive eligibility determination.

The state requires that a written application be signed by the applicant, parent or representative, as appropriate. @ Yes C No C The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS.

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

{m] The presumptive eligibility determination is based on the following factors:

The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is [M) being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid {115 demonstration for that group)

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

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

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

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Table of Contents

State/Territory Name: North Carolina State Plan Amendment (SPA) #: 14-0004-MM1

This file contains the following documents in the order listed:

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

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

Atlanta Regional Office

61 Forsyth Street, Suite 4T20

Atlanta, Georgia 30303

CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

August 15, 2014

Ms. Sandra D. Terrell, MS, R.N.

Chief Operating Officer

Division of Medical Assistance

North Carolina Department of Health and Human Services 2501 Mail Service Center

Raleigh, North Carolina 27699-2501

Attention: Teresa Smith RE: North Carolina Title XIX State Plan Amendment, Transmittal # NC 14-0004-MM1 Dear Ms. Terrell:

Enclosed is an approved copy of North Carolina’s State Plan Amendment (SPA) 14-0004-MM1, which was submitted to CMS on June 20, 2014. SPA 14-0004-MM1 amends the S28 Pregnant Women PDF in MAGI-Based Eligibility Group SPA in North Carolina’s State Plan originally approved on December 10, 2013 and had an effective date of January 1, 2014. NC 14-0004-MMI1 removes the requirement for citizenship for presumptive eligibility from the state plan.

Enclosed is a copy of the 179, and the new State Plan pages $28-1 through S28-6 to be incorporated within a separate section at the back of North Carolina’s approved State Plan. The effective date of the SPA is August 15, 2014. The approval date of the SPA is August 12, 2014.

If you have any questions, please contact Elaine Elmore at 404-562-7408 or

Elaine.Elmore@cms.hhs.gov.

Sincerely, //s// Jackie Glaze

Associate Regional Administrator Division of Medicaid & Children’s Health Operations

ccs: Aldona Z. Wos, M.D., Secretary NC Department of Health and Human Services Robin G. Cummings, M.D., Director

Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: North Carolina

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- 14-000

Proposed Effective Date

| 08/15/2014 (mm/dd/yyyy)

Federal Statute/Regulation Citation

| 42 CFR Pai

Federal Budget Impact

Federal Fiscal Year Amount

First Year | 2014 gl 0.00

Second Year | 2015 gl 0.00

Subject of Amendment

Character count out of 2000

Pregnant Women- This SPA “2

aL oe

Governor's Office Review

Governor's office reported no comment

Comments of Governor's office received

4 a Bi

No reply received within 45 days of submittal

Describe:

& Other, as specified

Describe:

Character count: out of 2000

Secretary =

Ll J 4 Signature of State Agency Official Submitted By:

Teresa Smith Last Revision Date: Jul 31, 2014

Submit Date: Jun 20, 2014

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

42 CFR 435.116

1902(a)(10)(A)(i)(IIT) and (IV) 1902(a)(10)(A)(ii)(1), (IV) and (IX) 1931(b) and (d)

1920

[m) Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. The state attests that it operates this eligibility group in accordance with the following provisions: [iM] Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4.

Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110.

@ Yes C No

aw MAGI-based income methodologies are used in calculating household income. Please refer as necessary to $10 MAGI-Based Income Methodologies, completed by the state.

[M] Income standard used for this group [) Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.)

The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July |, 1989, had authorizing legislation to do so.

C Yes @No The minimum income standard for this eligibility group is 133% FPL.

[@] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group.

The state's maximum income standard for this eligibility group is:

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(LX) (optional poverty level-related pregnant women), 1902(a)(10)

° (A)(ii)(D (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)ULV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

TN No: 14-0004-MM1 Approval Date: 08/12/14 Effective 08/15/14 North Carolina $28-1

bene eee

Ss Medicaid Eligibility

“ETE 708 EONAR A CCAD Se

The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-

Cc related pregnant women), 1902(a)(10)(A \(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(1) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(TV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as ~” of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

Cc The state's effective income level for any population of pregnant women under a Medicaid | 115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

C 185% FPL

The amount of the maximum income standard is:} 196 % FPL

{M] Income standard chosen Indicate the state's income standard used for this eligibility group: C The minimum income standard (@ The maximum income standard ; C Another income standard in-between the minimum and maximum standards allowed. {@] There is no resource test for this eligibility group. {@] Benefits for individuals in this eligibility group consist of the following: C All pregnant women eligible under this group receive full Medicaid coverage under this state plan.

A Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services.

Pregnancy-related services, as defined at 42 CFR 440.210 (a)(2), include prenatal, delivery, postpartum and family planning services, as well as services related to conditions which may complicate pregnancy.

Full Medicaid coverage is provided only for pregnant women with income at or below the income limit described below:

{™] Minimum income limit for full Medicaid coverage

The minimum income standard used for full coverage under this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in $14 AFDC Income Standards.

The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard.

[B] Maximum income limit for full Medicaid coverage

TN No: 14-0004-MM1 Approval Date: 08/12/14 Effective 08/15/14 North Carolina S28-2

‘CMS Medicaid Eligibility

The highest effective income level for coverage under section 1902(a)(10)(A)(i)(III) (qualified pregnant (@) women) or section 1931(b) and (d) (low-income families) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent standard.

The highest effective income level for coverage under section 1902(a)(10)(A)(i)(III) (qualified pregnant © women) or section 193 1(b) and (d) (low-income families) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent standard.

, The state's effective income level for any population of pregnant women under a Medicaid 1115 ~~” demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL.

The state's effective income level for any population of pregnant women under a Medicaid 1115 “ demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL.

The amount of the maximum income limit for full Medicaid coverage is:

© A percentage of the federal poverty level: %

@ A dollar amount

The standard is as follows:

©@ Statewide standard C Standard varies by region

C Standard varies by living arrangement

© Standard varies in some other way

TN No: 14-0004-MM1

Approval Date: 08/12/14 North Carolina

Effective 08/15/14 $28-3

Medicaid Eligibility

Additional incremental amount

Household size | Standard ($) @ Yes CNo

434

Increment amount $ |78

569

667

744

824

901

975

1,036

1,096

1,169

The dollar amounts increase automatically each year C Yes @ No

[] Income limit chosen for full Medicaid coverage: @ The minimum income limit © The maximum income limit C Another income limit in-between the minimum and maximum standards allowed. [mi] Presumptive Eligibility

The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity.

@ Yes (| No [m] The presumptive period begins on the date the determination is made.

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

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

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

TN No: 14-0004-MM1 Approval Date: 08/12/14 Effective 08/15/14 North Carolina S28-4

Medicaid Eligibility

[®] There may be no more than one period of presumptive eligibility per pregnancy.

A written application must be signed by the applicant or representative. @ Yes CM No

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

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

[&] The presumptive eligibility determination is based on the following factors: [m] The woman must be pregnant [m) Household income must not exceed the applicable income standard at 42 CFR 435.116. [X] State residency

CJ Citizenship, status as a national, or satisfactory immigration status

i The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group.

A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities : used to determine presumptive eligibility for this eligibility group: R Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan

oO Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act

oO Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990

Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental (1) Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966

oO Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP)

oO Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

(1 Is an elementary or secondary school operated or supported by the Bureau of Indian A ffairs (J Isa state or Tribal child support enforcement agency under title 1V-D of the Act

Oo Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

TN No: 14-0004-MM1 Approval Date: 08/12/14 Effective 08/15/14 North Carolina $28-5

CCMSsS Medicaid Eligibility

oO Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title [V-A of the Act

Is an organization that determines eligibility for any assistance or benefits provided under any program

Oo of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.)

x Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization

(CZ) Other entity the agency determines is capable of making presumptive eligibility determinations:

The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No: 14-0004-MM1 Approval Date: 08/12/14 Effective 08/15/14 North Carolina $28-6

Table of Contents

State/Territory Name: North Carolina State Plan Amendment (SPA) #: 14-0005-MM1

This file contains the following documents in the order listed:

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

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

Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

September 23, 2014

Ms. Sandra D. Terrell, MS, R.N.

Chief Operating Officer

Division of Medical Assistance

North Carolina Department of Health and Human Services 2501 Mail Service Center

Raleigh, North Carolina 27699-2501

Attention: Teresa Smith

RE: North Carolina Title XIX State Plan Amendment, Transmittal # NC 14-0005-MM1

Dear Ms. Terrell:

We reviewed the proposed amendment to the North Carolina Medicaid State Plan Amendment (SPA) NC 14-0005-MM1 that was received in the Regional Office on September 15, 2014. The amendment establishes the state’s election of the MAGI-based eligibility for the family planning optional eligibility group in the Medicaid state plan.

Based on the information provided, we are now ready to approve the Medicaid State Plan Amendment NC 14-0005-MM1. This SPA was approved on September 22, 2014. The effective date of this amendment is October 1, 2014. We are enclosing the S59 approved plan page.

If you have any questions or need any further assistance, please contact Elaine Elmore at (404) 562-7408.

Sincerely,

/Is//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children's Health Operations

Enclosures

cc: Aldona Z. Wos, M.D., Secretary North Carolina Department of Health and Human Services Robin G. Cummings, M.D.

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: North Carolina

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-14-000

Proposed Effective Date

| 10/01/2014 (mm/dd/yyyy)

Federal Statute/Regulation Citation

fv902(aycic

Federal Budget Impact

Federal Fiscal Year Amount

First Year

2015

gl -515129.0€

Second Year

2016

ij

| -499675.0( $

Subject of Amendment

Character count dl out of 2000

oo000

Fraity planning Services- This “|

ae —

Governor's Office Review

Governor's office reported no comment

Comments of Governor's office received

Describe:

4

a so

No reply received within 45 days of submittal

& Other, as specified

Describe:

Character count: out of 2000

Secretary 4

a]

Ll aa Signature of State Agency Official Submitted By: Teresa Smith

Last Revision Date: Sep 15, 2014

Submit Date: Sep 15, 2014

State Name;|North Carolina | OMB Control Number: 0938-1148 Transmittal Number: NC - 14 - 0005 Expiration date: 10/31/2014

ca ee

1902(a)(10)(A (ii) CX XI) 42 CFR 435.214

Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214.

@ Yes CNo

The state attests that it operates this eligibility group in accordance with the following provisions: [M] The individual may be a male or a female. [M] Income standard used for this group

[8] Maximum income standard

The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for this eligibility group.

The state's maximum income standard for this eligibility group is the highest of the following:

The state's current effective income level for the Pregnant Women eligibility group (42 CFR 435.116) under the Medicaid state plan.

C The state's current effective income level for pregnant women under a Medicaid 1115 demonstration. C The state's current effective income level for Targeted Low-Income Pregnant Women under the CHIP state plan.

C The state's current effective income level for pregnant women under a CHIP 1115 demonstration.

The amount of the maximum income standard is: |196 % FPL

[ Income standard chosen The state's income standard used for this eligibility group is: © The maximum income standard

@ Another income standard less than the maximum standard allowed.

The amount of the income standard is: |195 % FPL

aw MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state.

TN No.: 14-0005-MM1 Approval Date: 09-22-14

E i : North Carolina 559-1 ffective Date: 10/01/14

Ss Medicaid Eligibility

DOTS FOE ECAR A MOCANRD ICT

[MJ In determining eligibility for this group, the state uses the following household size: KX All of the members of the family are included in the household (C Only the applicant is included in the household (] The state increases the household size by one [Mi In determining eligibility for this group, the state uses the following income methodology:

Cc The state considers the income of the applicant and all legally responsible household members (using MAGI-based methodology).

C© The state considers only the income of the applicant. [Ml] Benefits for this eligibility group are limited to family planning and related services described in the Benefit section. [@] Presumptive Eligibility

The state makes family planning services and supplies available to individuals covered under this group when determined presumptively eligible by a qualified entity.

C Yes @No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20140415

TN-No.: 14-0005-MM1 Approval Date: 09-22-14 Effective Date: 10/01/14 North Carolina $59-2

Table of Contents

State/Territory Name: North Carolina State Plan Amendment (SPA) #: 14-016 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

August 5, 2014

Dr. Robin Cummings, Director Division of Medical Assistance Department of Health and Human Services 2501 Mail Service Center Raleigh, NC 27699-2501

Re: North Carolina State Plan Amendment, 14-016

Dear Dr. Cummings:

We have reviewed the state plan amendment (SPA) 14-016 that was received in the Regional Office on June 19, 2014. This amendment modifies the physician’s attestation date from June 30, 2013 to June 30, 2014. This modification will allow physicians who successfully attest as of the new cut-off date to receive Enhanced Affordable Care Act payments for any claim with dates of service on or after January 1, 2013. The requested effective date is June 1, 2014.

Based on the information provided, the Medicaid State Plan Amendment NC-14-016 was approved on August 5, 2014. The effective date of this SPA is June 1, 2014. We are enclosing the approved Form HCFA-179 and the approved plan page.

If you have any additional questions or need further assistance, please contact Clarence Lewis at 803-898-7647, or Donald Graves at 919-828-2999.

Sincerely,

//s//

Jackie Glaze Associate Regional Administrator Division of Medicaid and Children’s Health Operations

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF | 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 14-016 NC

FOR: HEALTH CARE FINANCING ADMINISTRATION

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

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

4. PROPOSED EFFECTIVE DATE

June 1, 2014

5. TYPE OF PLAN MATERIAL (Check One):

(NEW STATE PLAN

(LJ AMENDMENT TO BE CONSIDERED AS NEW PLAN

&) AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION:

42 CFR 447.400, 447.410, and 447.415

7. FEDERAL BUDGET IMPACT:

a. FFY 2014 b. FFY 2015

$21,389,528 $ 5,347,963

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-B, Section 5, Page 1b

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

Attachment 4.19-B, Section 5, Page 1b

10. SUBJECT OF AMENDMENT:

Physician Enhanced Payments

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

K] OTHER, AS SPECIFIED: Secretary

12. SIGNATURE OF STATE AGENCY OFFICIAL: /Is//

13. TYPED NAME: Aldona Z. Wos, M.D.

14. TITLE: Secretary

15. DATE SUBMITTED: 06-19-14

16. RETURN TO:

Office of the Secretary

Department of Health and Human Services 2001 Mail Service Center

Raleigh, NC 27699-20014

FORM HCFA-179 (07-92)

Attachment 4.19-B Section 5, Page 1b

State Plan Under Title XIX of the Social Security Act Medical Assistance Program State: North Carolina

Increased Primary Care Service Payment 42 CFR 447.405, 447.410, 447.415

(3) If attesting to Board Certification, the certification must remain valid for the entire time these supplemental payments are received by the physician.

(4) Physician Assistants and Nurse Practitioners must identify their supervising physician who qualifies for the enhanced payment.

(5)Payments will begin on or after January 1, 2013, but not prior to physician, physician assistant, or nurse practitioner’s attestation. EXCEPTION: Physicians who attest on or before by June 30, 2014 will be eligible for payments retroactive to the later of January 1, 2013, or the date upon which they met all requirements for higher payment under the Federal regulations

Primary Care physicians enrolling in calendar year 2013 or 2014 without board certification with attestation will require verification of 60% billed and paid primary care services as defined in section 1902 for the prior month of calendar year 2012.

ACA physician’s billing history will be reviewed at the end of 2013 and 2014 to confirm that 60 percent of codes billed and paid during CY 2013 and 2014 were primary care services eligible for payment under sections 1902(a)(13)(C) and 1902(jj) of the Act.

Federally Qualified Health Centers, Rural Health Centers, Schoo! Based Health Centers, Health Departments and CABHA providers are not eligible for enhanced primary care services payments.

There shall be no cost settlement for any Primary Care Services provider in any setting for these services reimbursed at the enhanced ACA rates.

These payments will terminate on December 31, 2014.

TN. No. 14-016 Approval Date: 08-05-14 Eff. Date: 06/01/2014 Supersedes TN. No. 13-001

Table of Contents State/Territory Name: 1RUWK&DUROLQD State Plan Amendment (SPA) #:  This file contains the following documents in the order listed:  Approval Letter  &RPSDQLRQ/HWWHU  Summary Form (with 179-like data)  Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group August , 2020 Mr. Dave Richard Deputy Secretary Division of Medical Assistance North Carolina Department of Health and Human Services 2501 Mail Service Center Raleigh, North Carolina 27699-2501 Dear Mr. Richard: We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number 15-0001-MM2 on December 29, 2015. This SPA includes North Carolina’s alternative single streamlined online and paper applications only. Please be informed that this SPA was approved $XJXVW   with an effective date of December 1, 2015. The approved plan pages and CMS 179 form are included in this letter. Also enclosed is a letter being sent as a companion to our approval of this NC SPA 15-0001-MM2. If you have any additional questions or need further assistance, please contact Charles Friedrich at (404)562-7404 or Charles.Friedrich@cms.hhs.gov. 6incerely, James *ScottDirector Division of Program Operations Enclosures

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group August , 2020 Mr. Dave Richard Deputy Secretary Division of Medical Assistance North Carolina Department of Health and Human Services 2501 Mail Service Center Raleigh, North Carolina 27699-2501 RE: North Carolina Application SPA 15-0001-MM2 Dear Mr. Richard: This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) 15-0001-MM2, which was submitted to CMS on December 29, 2015. This SPA approval will be effective as of December 1, 2015. Approval of SPA 15-0001-MM2 included approval of the alternative single streamlined online and paper applications developed by the state. Until November 2020, North Carolina will use an interim alternative single streamlined online application. Until September 2020, North Carolina will use interim alternative single streamlined paper applications. The state will revise the alternative single streamlined online and paper applications as described below. Alternative Single Streamlined Online Application Necessary changes: Date by which changes will be completed: 1. The state will make immigration status document type detail fields optional, such that applicants can continue the application without providing detailed information such as SEVIS ID number, alien or I-94 number. November 2020 Alternative Single Streamlined Paper Application (dma-5200-ia) Necessary changes: Date by which changes will be completed:

1. The state will remove the following questions regarding emergency Medicaid (9b): If you are not a U.S. citizen or U.S. national, have you had a medical emergency in the past 3 months, or do you expect a medical emergency in the next 45-90 days. Ƒ Yes Ƒ No Date of Emergency: Name of Provider: September 2020 2. The state will include the following instructional text at the top of Appendix E, which requests detailed information regarding medical bills in the past 3 months: “This form or the medical bills are not required for you to submit an application. If needed, this information may be requested by a caseworker.” September 2020 Alternative Single Streamlined Paper Application Short Form (dma-5201-ia) Necessary changes: Date by which changes will be completed: 1. The state will remove the following questions regarding emergency Medicaid (22b): If you are not a U.S. citizen or U.S. national, have you had a medical emergency in the past 3 months, or do you expect a medical emergency in the next 45-90 days. Ƒ Yes Ƒ No Date of Emergency: Name of Provider: September 2020 2. The state will include the following instructional text at the top of Appendix E, which requests detailed information regarding medical bills in the past 3 months: “This form or the medical bills are not required for you to submit an application. If needed, this information may be requested by a caseworker.” September 2020 Please submit the revised alternative single streamlined online application to CMS for review no later than November 2020, to ensure approval. Please submit the revised alternative single streamlined paper applications to CMS for review no later than September 2020, to ensure approval. We continue to be available to provide technical assistance.

If you have any additional questions or need further assistance, please contact Charles Friedrich at (404) 562-7404 or Charles.Friedrich@cms.hhs.gov. Sincerely, -DPHV* Scott Director Division of Program Operations Enclosures

Medicaid State Plan Eligibility: Summary Page (CMS 179) 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. Proposed Effective Date (mm/dd/yyyy) Federal Statute/Regulation Citation Federal Budget Impact Subject of Amendment Medicaid Eligibility Process-Bucket 2 Amending SPA to include the integrated/alternative application for approval. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Secretary Signature of State Agency Official State/Territory name: North Carolina NC-15-0001 12/01/2015 42 CFR 435.10; 42 CFR 435, Subpart J and Subpart M Federal Fiscal Year Amount First Year 2015 $ 0.00 Second Year 2016 $ 0.00 ᄞ ᄟ Submitted By: Betty Staton Last Revision Date: Aug 7, 2020 Submit Date: Dec 29, 2015 Page 1 of 1 NC.0434.R00.01 - Dec 01, 2015 08/07/2020 https://wms-mmdl.cms.gov/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

Page 1 of 2 Medicaid Eligibility Transmittal Number: NC State Name: North Carolina OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 - 15 - 0001 General Eligibility Requirements Eligibility Process S94 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. ✔ Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, 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 in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. An attachment is submitted. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes No 7100 $SSURYDOGDWH  (IIHFWLYH'DWH  North Carolina 6 

Page 2 of 2 Medicaid Eligibility Indicate the other electronic means below: Name of Method Description + x The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals. ✔ Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations 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 435.916: ✔ Once every 12 months ■ 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 additional information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ■ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ■ Once every 12 months Once every 6 months Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. V.20140415 7100 $SSURYDO'DWH  (IIHFWLYH'DWH  North Carolina 6 

Table of Contents

State/Territory Name: North Carolina State Plan Amendment (SPA) #:16-0001-MM4 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Atlanta Regional Office 61 Forsyth Street, Suite 4T20 Atlanta, Georgia 30303

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

February 24, 2017

Mr. Dave Richard Deputy Secretary for Medical Assistance North Carolina Department of Health and Human Services 1985 Umstead Drive Raleigh, NC 27699-2501

RE: SPA 16-0001

Dear Mr. Richard:

Enclosed is an approved copy of North Carolina’s state plan amendment (SPA) 16-0001-MM4, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on December 9, 2017. SPA 16-0001-MM4 amends the current Single State Agency SPA by adding the Eastern Band of Cherokee Indians (EBCI) as an entity responsible for determinations of eligibility and appeals/fair hearings in accordance with the North Carolina State Law 2016-94, Section 12C.2(a). This SPA was approved on February 23, 2017. The effective date of this SPA is April 1, 2017.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section in the back of North Carolina’s approved state plan, as well as a summary of the state plan pages which are superseded by SPA 16-0001-MM4, which should be incorporated into a separate section in the front of the state plan.

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Kenni Howard at 404-562-413 or by email at kenni.howard@cms.hhs.gov.

Sincerely,

//s//

Jackie Glaze

Associate Regional Administrator

Division of Medicaid & Children’s Health Operations

Enclosures

NC.3197.R00.00 - Apr 01, 2017 Page | of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: North Carolina

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-16-0001

04/01/2017 | (mm/dd/yyyy)

Federal Statute/Regulation Citation |42 CFR 431.10

Federal Budget Impact Federal Fiscal Year Amount

First Year $10.00 | Second Year $[0.00 |

Subject of Amendment Single State Agency (Federally Recognized Tribe)

Governor's Office Review “2 Governor's office reported no comment

‘2 Comments of Governor's office received Describe:

ay

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

Describe:

Secretary

Signature of State Agency Official

Submitted By: Teresa Smith Last Revision Date: Jan 13, 2017 Submit Date: Dec 9, 2016

https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 01/20/2017

Page 1 of 13 Medicaid Administration Transmittal Number: NC State Name: North Carolina OMB Control Number: 0938‐1148 Expiration date: 10/31/2014 - 16 - 0001 State Plan Administration Designation and Authority A1 42 CFR 431.10 Designation and Authority State Name: North Carolina As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. Name of single state agency: Department of Health and Human Services Type of Agency: Title IV-A Agency Health Human Resources Other Type of Agency Department of Health and Human Services & Title IV-A Agency The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.) The state statutory citation for the legal authority under which the single state agency administers the state plan is: North Carolina General Statute §108A-54 The single state agency supervises the administration of the state plan by local political subdivisions. Yes No The state statutory citation for the legal authority under which the agency supervises the administration of the plan on a statewide basis is: North Carolina General Statute §108A-54 The state statutory citation under which the single state agency has legal authority to make rules and regulations that are binding on the political subdivisions administering the plan is: North Carolina General Statutes §108A-54 and 108A-54.1B The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program has been provided. ✔ TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A1-1

Page 2 of 13 Medicaid Administration An attachment is submitted. The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies. The single state agency administers the entire state plan under title XIX (i.e., no other agency or organization administers any portion of it). Yes No Waivers of the single state agency requirement have been granted under authority of the Intergovernmental Cooperation Act of 1968. The waivers are still in effect. Yes No Enter the following information for each waiver: Remove Date waiver granted (MM/DD/YY): 12/27/12 The type of responsibility delegated is (check all that apply): Determining eligibility Conducting fair hearings Other Name of state agency to which responsibility is delegated: Office of Administrative Hearings (OAH) Describe the organizational arrangement authorized, the nature and extent of responsibility for program administration delegated to the above named agency, and the resources and/or services of such agency to be utilized in administration of the plan: The Office of Administrative Hearings will make final agency decisions in contested Medicaid beneficiary and provider cases as defined in paragraphs (1) and (2) below. 1. "Contested Medicaid beneficiary cases" are those defined in N.C.G.S. §150B-22 in which the single state Medicaid agency or one of its contractors or agents denies, reduces, terminates or suspends (or alleges such a decision was not acted upon with reasonable promptness), a Medicaid-reimbursable service. In all contested Medicaid beneficiary cases, OAH shall dismiss appeals when the conditions described in 42 CFR §431.223 are present, as set forth in N.C.G.S. §108A-70.9B(b)(4). 2. In all contested cases in which an enrolled Medicaid provider, or provider applicant, is challenging any decision of the single state Medicaid agency which directly or indirectly affected the provider or applicant substantially in their person, property, or employment as described in N.C.G.S. §150B-2(6). OAH shall agree to dismiss all appeals: (a) that are filled outside of the timeline set forth in N.C.G.S. §150B-23(f); (b) where the petitioner fails to timely serve the single state Medicaid agency; and (c) where the petitioner fails to pay the filing fee. Further, OAH shall agree to dismiss or impose another sanction as provided by law, all appeals where either party fails to file a Prehearing Statement or respond to discovery prior to the hearing, or where either party fails to appear at a scheduled hearing without good cause. TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A1-2

Page 3 of 13 Medicaid Administration The methods for coordinating responsibilities among the agencies involved in administration of the plan under the alternate organizational arrangement are as follows: The parties to this waiver acknowledge that the Division of Medical Assistance(DMA) delegates the authority to make final decisions regarding beneficiary and provider contested cases as defined in paragraphs (1) and (2) above to the North Carolina Office of Administrative Hearings (OAH). As a condition precedent for the State of North Carolina to receive federal financial participation for the functions authorized by this waiver of the single state agency requirement found at 42 C.F.R. § 431.10(e), the North Carolina Office of Administrative Hearings (“OAH”) must acknowledge and agree in writing that it will act as a neutral and impartial decision-maker on behalf of the North Carolina single state Medicaid agency in adjudicating contested Medicaid cases and that it will comply with all applicable federal and state laws, rules and regulations governing the Medicaid program. In addition, OAH acknowledges and agrees that, except as allowed by law, enrolled Medicaid providers have no property or liberty right in initial or continued participation or enrollment in the North Carolina State Medicaid program. OAH acknowledges and also agrees that the issue to be determined at final hearings conducted in accordance with this waiver is whether the single state Medicaid agency or one of its contractors or agents exceeded its authority or jurisdiction, acted erroneously, failed to use proper procedure, acted arbitrarily or capriciously, and/or failed to act as required by law or rule; that it will conduct de novo reviews in beneficiary cases as set forth below; that it will cooperate with any and all federal or state audits, monitoring, or oversight necessary to substantiate that OAH expenditures are valid and reasonable; that it will assist DMA in tracking and reporting of Medicaid appeal decisions as required by law; and that it will comply with each of the following conditions of this waiver: Except where agreed to by the parties or for other good cause, OAH agrees to schedule, hear and issue decisions in contested Medicaid beneficiary cases within the time period set forth in 42 C.F.R. §431.244(f) and N.C.G.S. §108A-70.9B(b)(1). OAH shall schedule, hear and issue decisions in contested Medicaid provider cases within 180 days of the date the appeal is filed with OAH, except that hearings in cases where OAH has issued a temporary restraining order (“TRO”), stay or injunction shall be expedited as soon as practicable. The time for the appeal process may be extended in the event of delays caused or requested by the single state Medicaid agency. OAH shall only issue TROs, stays or injunctions to maintain the status quo in contested beneficiary and provider Medicaid cases when the petitioner meets the requirements contained in Rule 65 of the North Carolina Rules of Civil Procedure. Any TRO so issued shall be in effect for no longer than allowed by law and shall not be continued except as provided in Rule 65. In contested Medicaid beneficiary cases, OAH shall issue TROs, stays or injunctions which require the single state Medicaid agency or a Local Management Entity operating a Prepaid Inpatient Health Plan in accordance with 42 CFR Part 438 (LME/PIHP) to continue an authorization for Medicaid- reimbursable service(s), or to authorize service(s) at any particular level or frequency, during the pendency of an appeal to the extent required to meet the requirements of 42 CFR 431.230. DMA and OAH shall allow all parties’ witnesses to appear and testify by telephone at hearings, including but not limited to any expert witnesses, unless good cause is shown to require in person appearance by specific witnesses. When a continuance is necessary, OAH shall only grant requests filed by either party for good cause shown, and shall ensure that hearings are not unreasonably delayed. In contested Medicaid cases, OAH shall issue decisions that are based on the evidence introduced before the record is deemed closed by the Administrative Law Judge. TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A1-3

Page 4 of 13 Medicaid Administration To the extent allowed under Rule 32 of the North Carolina Rules of Civil Procedure, OAH may consider deposition testimony in addition to other allowable testimony as evidence at the hearing on the merits. Affidavits and deposition testimony may be permitted for use as evidence in hearings on motions for preliminary injunctive relief as allowed by law. Subject to applicable law, OAH shall require in the absence of good cause that all discovery be completed at least thirty (30) days prior to the scheduled hearing date, shall comply with the North Carolina Rules of Civil Procedure in contested Medicaid provider cases, and may limit discovery in such cases to provide for the prompt disposition of the contested case and to ensure that the burden or expense of the proposed discovery does not outweigh its likely benefit, considering the needs of the case, the amount in controversy, the parties’ resources, the importance of the issues at stake in the action, and the importance of the discovery in resolving the issues. In all contested Medicaid provider cases, OAH may allow both sides to prepare and file proposed decisions within thirty (30) days of the date of the hearing, unless either party requests a transcript of the hearing, in which case proposed decisions shall be due within thirty (30) days of the date the transcript is prepared and served on the parties. In contested Medicaid beneficiary cases, OAH shall issue decisions that are based on the evidence introduced before the record is deemed closed by the Administrative Law Judge and the applicable provision(s) of federal or state laws, rules and regulations supporting the decision in accordance with 42 CFR § 431.244 and N.C.G.S. § 108A-70.9B(f). DMA retains oversight of the State Plan and will establish a process to monitor the entire appeals process, including the quality and accuracy of the final decisions made by OAH. Add The agency that administers or supervises the administration of the plan under Title X of the Act as of January 1, 1965, has been separately designated to administer or supervise the administration of that portion of this plan related to blind individuals. The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Indicate which agency determines eligibility for any groups whose eligibility is not determined by the Federal agency: Medicaid agency TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A1-4

Page 5 of 13 Medicaid Administration Title IV-A agency An Exchange The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are: Medicaid agency An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies. Yes No State Plan Administration Organization and Administration A2 42 CFR 431.10 42 CFR 431.11 Organization and Administration Provide a description of the organization and functions of the Medicaid agency. The North Carolina Department of Health and Human Services (DHHS) is a cabinet agency, led by a Secretary appointed by the Governor. North Carolina DHHS divisions and offices fall under four broad service areas - health, human services, administrative, and support functions described below. Division of Aging and Adult Services Division of Child Development and Early Education Division of Health Benefits Division of Health Service Regulation and Office of Internal Audit Division of Medical Assistance Division of Mental Health, Developmental Disabilities and Substance Abuse Services Division of Rural Health and Community Care Division of Public Health Division of Services for the Blind Division of Services for the Deaf and Hard of Hearing Division of Social Services Division of Behavioral Health Developmental Disability Services/State Operated Healthcare Facilities Division of Vocational Rehabilitation Services HUMAN SERVICES: An organizational umbrella led by a Deputy Secretary that incorporates services provided through the Divisions of Social Services, Aging and Adult Services, Child Development and Early Education, Vocational Rehabilitation Services, Services for the Deaf and Hard of Hearing and Services for the Blind. DIVISION OF AGING AND ADULT SERVICES: The Division of Aging and Adult Services (DAAS) promotes successful aging for North Carolina's older population and their families, advancing their social, health, and economic well-being. Working closely with Area Agencies on Aging, senior advocates and local service providers, the division supports the independence and dignity of impaired older persons through such home and TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A2-5

Page 6 of 13 Medicaid Administration community services as in-home aide care, congregate and home-delivered meals, transportation, adult day care, housing and home improvement, and respite for family caregivers. The Division also ensures protection of North Carolina’s most vulnerable adults of all ages by the delivery of Adult Protective Services and Guardianship Services through the State’s 100 county departments of social services. These core services protect against abuse, neglect and exploitation, and provide surrogate decision makers with the appointment of a guardian when older adults and adults with disabilities are unable to make and communicate important decisions about their well-being. The Division promotes the rights of residents of nursing homes and adult care homes through its Ombudsman Program, and uses Senior Centers as local resources for information and access to a wide range of services and programs. DAAS also is committed to helping younger generations prepare to enjoy their later years. DIVISION OF CHILD DEVELOPMENT AND EARLY EDUCATION: The Division of Child Development and Early Education (CDEE) supports the safety, care and early education of children by licensing, monitoring and regulating over 7,200 child day care facilities statewide. Nearly 250,000 of North Carolina's children age are served regulated day care centers and homes licensed by the division. Licensing consultants make unannounced visits to child care facilities to make sure they are complying with requirements for their star rating (level of licensure). The Division also provides technical assistance and other supports to help child care facilities enhance their program and education standards, and to accommodate children with special needs and other populations. The Division completes criminal record checks for everyone employed in regulated child care programs. Background checks are performed for adoptive and foster parents, nursing homes employees, family and adult care homes, mental health facilities, emergency medical services and employees of Department agencies. The North Carolina Subsidized Child Care program is supervised by the Division, and provides financial assistance to eligible families through county departments of social services to help pay for child care. The service benefits over 75,000 children monthly from low-income families. Assistance is available to support parents' employment or education, child developmental needs, child protective services and child welfare services. The Division administers the NC Pre-K Program, which provides high-quality educational experiences to enhance school readiness for nearly 28,000 at-risk, eligible four-year-olds. The Division also provides support for Smart Start in its mission to advance a high quality, comprehensive, accountable system of care and education for every child beginning with a healthy birth. DIVISION OF SOCIAL SERVICES: The Division of Social Services (DSS) works in cooperation with the Social Services Commission, the 100 county departments of social services, and other public and private entities to protect children, strengthen families and help all North Carolinians to achieve maximum self-sufficiency. The Division provides training, technical assistance and consultation to the local staff who work in programs for families and children, including Medicaid, North Carolina Health Choice, Child Welfare, Family Support, Work First, Child Support, Food and Nutrition Services, Low Income Home Energy Assistance Program and Refugee Services. WORKFORCE SERVICES: An organizational umbrella that incorporates services provided through the Division of Vocational Rehabilitation Services its two regional workforce operations, Independent Living, and the Divisions of Services for the Blind and Services for the Deaf and Hard of Hearing. DIVISION OF SERVICES FOR THE BLIND: The Division of Services for the Blind provides treatment, rehabilitation, education and independent living alternatives for blind and visually impaired residents of North Carolina. Through vocational rehabilitation, the Division helps people find and keep jobs. The Division also promotes the prevention of blindness through educational programs. The Division’s programs also include the Business Enterprises Program providing opportunities for people who are legally blind to work in food service in vending facilities and the Rehabilitation Center for the Blind offering training in a residential setting to TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A2-6

Page 7 of 13 Medicaid Administration enable individuals with vision loss to achieve career and personal goals. The Governor Morehead School, the State's residential school for the blind, is co-located with the Division’s home office in Raleigh, but operates under the Department of Public Instruction. DIVISION OF SERVICES FOR THE DEAF AND THE HARD OF HEARING: The State’s over one million deaf and hard of hearing citizens find the assistance and information from the Division of Services for the Deaf and the Hard of Hearing. The Division works to ensure that all deaf, hard of hearing or deaf-blind North Carolinians have the ability to communicate their needs, and to receive information easily and effectively in all aspects of their lives. The Division, in collaboration with its partners, works to provide deaf, hard of hearing and deaf-blind North Carolinians and their families the information, skills and tools they need to achieve effective communication and access to resources in their communities, resulting in independence and full participation in society. The Division accomplishes this mission through providing advocacy, information, counseling, skills development and telecommunications access to North Carolinians who are deaf, hard of hearing and deaf-blind through its seven Regional Centers. DIVISION OF VOCATIONAL REHABILITATION SERVICES: The Division of Vocational Rehabilitation Services assists North Carolinians with disabilities in finding and maintaining employment and living independently in their communities. Vocational rehabilitation counselors work with business and community agencies to help them prepare their work-sites to accommodate employees who have physical, mental health, intellectual/developmental, hearing/communicative or substance abuse disabilities. The Division also provides services that encourage and reinforce independent living options for people with disabilities through the Independent Living Rehabilitation Program and the Assistive Technology Program. Rehabilitation counselors in vocational rehabilitation offices across the State are available to assist people with disabilities with individualized plans to meet their unique needs. Counselors provide vocational evaluations, job training, guidance and counseling. They help people with disabilities transition from rehabilitation to employment and educate them about the kinds of technology available that could increase independence. HEALTH SERVICES: An organizational umbrella led by a Deputy Secretary that incorporates services provided through the Division of Public Health and the Office of Rural Health and Community Care. DIVISION OF RURAL HEALTH AND COMMUNITY CARE: The Office of Rural Health and Community Care created within the Department in 1973. Its mission is to assist underserved communities and populations to develop innovative strategies for improving access, quality and cost-effectiveness of health care. Currently, the Office administers the following programs: Designation of health professional shortage areas; provider recruitment and loan repayment; safety net primary care infrastructure development; integration of behavioral, oral and physical health; migrant health programs; telepsychiatry; prescription assistance; and community network development. The Office provides funding and in- depth technical assistance to North Carolina’s safety net system, including rural health clinics, community health centers, local health departments, free clinics, school based health centers and critical access hospitals. The Office receives federal funding to serve as the Primary Care Office, State Office of Rural Health, Flex and SHIP Hospital Program, and a Community Health Center Migrant Health Program. In addition, the office assists the Division of Medical Assistance with initiatives for high-risk populations, such as the Centers for Medicare and Medicaid Services Children’s Health Insurance Program Reauthorization Act quality improvement demonstration. The Office is funded with federal, State and philanthropic resources and administers over 300 contracts that expand access to high quality health care for rural and underserved populations (Medicare, Medicaid, underinsured and uninsured). DIVISION OF PUBLIC HEALTH: The Division of Public Health works to protect, promote and preserve the health of North Carolinians through ethical, compassionate and evidence-based public health practice. The Division's wide range of programs and services are aimed toward protecting and improving the health of the people who live and work in North Carolina. Public health programs reach out to help TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A2-7

Page 8 of 13 Medicaid Administration build healthy families and communities, promote healthful living, lower the risk of disease and untimely death, and reduce the consequences of disease. The Division also gathers and analyzes statewide health data and statistics needed for making sound public health decisions and policies. The Division works with other Department divisions, State agencies and local health departments and in partnership with public and private groups to ensure a healthy North Carolina. DIVISION OF HEALTH SERVICE REGULATION AND OFFICE OF INTERNAL AUDIT: HEALTH SERVICE REGULATION: The Division of Health Service Regulation inspects, certifies, registers and licenses hospitals, nursing homes, adult care homes, mental health facilities, home care programs and other health facilities. INTERNAL AUDIT: Formally the office of the Internal Auditor, the Office of Internal Audit supports DHHS through a systematic, disciplined approach in the performance of independent, value-added audit, consulting and assurance services. DIVISION OF BEHAVIORAL HEALTH DEVELOPMENTAL DISABILITY SERVICES/STATE OPERATED HEALTHCARE FACILITIES: BEHAVIORAL HEALTH DEVELOPMENTAL DISABILITY SERVICES: The Division also devises statewide standards of care that are unique to each disability group and program, and that best meet the treatment and care needs of the populations served. It partners with regional advocacy groups, local management entity-managed care organizations (LME-MCOs), provider systems, the Division of Mental Health, Developmental Disabilities and Substance Abuse Services, and other stakeholders. STATE OPERATED HEALTHCARE FACILITIES: The Division of State Operated Healthcare Facilities oversees and manages a system of healthcare facilities that provide individualized, compassionate, efficient and quality care to adults and children with developmental disabilities, substance use disorders and psychiatric illnesses whose needs exceed the level of care available in the community. MENTAL HEALTH, DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE: The Division of Mental Health, Developmental Disabilities and Substance Abuse Services develops, provides and oversees publicly supported mental health, developmental disabilities and substance abuse services in North Carolina. The Division carries out its responsibilities through a system of local mental health authorities/managed care organizations known as Local Management Entities/Managed Care Organizations, as well as through contracts with local providers, advocacy organizations and hospitals. The Division collaborates with other State agencies within and outside of the Department to improve services and supports related to mental health, substance use, and intellectual and other developmental disabilities. The Division works closely with other agencies and stakeholders to address those issues, as well as juvenile justice, prescription drug abuse and other related areas. DIVISION OF MEDICAL ASSISTANCE: The Division of Medical Assistance is chiefly responsible for administering the federal Medicaid and Children’s Health Insurance Programs. The Division also manages several home and community-based waivers, which help the elderly and disabled remain in their homes by providing needed health and personal care services. The Pregnancy Medical Home program helps improve women's access to early prenatal care and preventive health care for low birth weight infants. North Carolina Community Care, Inc., through its provider networks, connects people with primary care doctors who manage their patient care needs. Health Check is an outreach program aimed at improving the quality of health care among low-income children. The program guarantees eligible children regular comprehensive health exams that include necessary immunizations, screenings and follow-up care. TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A2-8

Page 9 of 13 Medicaid Administration The Division of Medical Assistance is divided into five (5) subdivisions as follows: Clinical: The Clinical section is responsible for the overall administration of programs and clinical services covered in the North Carolina Medicaid Program. The section's staff develops clinical coverage policies and procedures, administers those policies and procedures, manages associated programs and contracts and provides related educational activities. Clinical Policy coordinates with other sections within the Division who are responsible for determining eligibility, reimbursement and monitoring program integrity of all covered services. Clinical Policy also provides program information to Medicaid recipients, service providers, and the general public. Business Information: The Business Information section is responsible for overseeing Research and Analytics, the Medicaid Management Information System (MMIS), and HIPAA. Operations: The Operations section is responsible for the coordination of Regulatory Affairs, Hearings and Appeals, Provider Services, Beneficiary Services, the call center, and Operational Excellence. The section is responsible for the coordination of DMA processes and protocols, access for providers and beneficiaries, assuring maximum efficiency for operations, and development of quality and risk management processes. Beneficiary Services, in partnership with DSS provides, oversight of the counties’ eligibility determinations and is responsible for developing eligibility policy. The controlling administrative rules adopted by the Department are codified at Title 10A of the North Carolina Administrative Code, Chapter 23, Subchapters A through E and G. Medicaid eligibility appeals are controlled by N.C.G.S. §108A-79. If an appellant aggrieved by a Medicaid eligibility determination is dissatisfied with a local appeal hearing decision in the county Department of Social Services, he or she may appeal to the Department’s Hearings and Appeals Section in the Division of Medical Assistance’s Operations section. The Hearing and Appeals Section oversees and provides hearing officers for de novo hearings (conducted according to Article 3 of N.C.G.S. §150B) in the county Departments of Social Services. The Department’s hearing officer renders a final agency decision. If a program applicant has exhausted all administrative remedies and is still aggrieved by the final agency decision, he or she may petition for judicial review under Article 4 of N.C.G.S. §150B, North Carolina’s Administrative Procedure Act. Compliance: The Compliance section is responsible for ensuring compliance, efficiency, and accountability within the Medicaid Program by detecting and preventing fraud, waste, program abuse, and by ensuring that Medicaid dollars are paid appropriately by implementing tort recoveries, pursuing recoupments, and identifying avenues for cost avoidance. Finance: The Finance section is responsible for overall provider reimbursement, financial audits, budget and forecasting, purchasing and contracting, and financial policy and reporting. DIVISION OF HEALTH BENEFITS: The Division of Health Benefits (DHB) was established by Session Law 2015-245 as a new division of the Department of Health and Human Services. DHB currently manages the process to transition NC Medicaid and NC Health Choice from fee-for-service to capitated managed care per state law. DHB will ultimately manage Medicaid and NC Health Choice operations upon implementation of Medicaid reform. OFFICE OF THE SECRETARY (ADMINISTRATIVE OFFICES): The Office of the Secretary, created by the Executive Organization Act of 1973, is a part of the Executive Branch of State Government. The Secretary, appointed by the Governor, serves as the principal officer of the Department and is responsible for the TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A2-9

Page 10 of 13 Medicaid Administration necessary management, development of policy, establishment of standards general health, social services and rehabilitation. The Office of the Secretary includes: Office of Budget and Analysis Office of Communications Office of Controller Office of General Counsel Office of Government Affairs Office of Human Resources Office of Information Technology Office of Procurement Contract and Grants Office of Property and Construction FINANCIAL OFFICE: OFFICE OF BUDGET AND ANALYSIS: The Division of Budget and Analysis develops, modifies and executes the North Carolina Department of Health and Human Services’ operating budget, and researches and analyzes issues that affect the Department's budgets. OFFICE OF CONTROLLER: The Office of the Controller sets and interprets all accounting and financial reporting policies and procedures for the Department as authorized by the rules and regulations of the Office of the State Controller and state statute and executes all accounting transactions for the Department of Health and Human Services. OFFICE OF PROPERTY AND CONSTRUCTION: The Division of Property and Construction supports DHHS by ensuring that the facilities needs are met statewide. Property and Construction manages the capital improvement program for DHHS which includes providing programming, budget requests, project management, architectural and engineering design, and construction administration services and by managing property leases and acquisitions. OFFICE PROCUREMENT CONTRACTS AND GRANTS: Procurement, Contracts and Grants was formerly called Purchasing and Contracts, this office encompasses the business functions of the Department to include grants. OFFICE OF HUMAN RESOURCES: The Division of Human Resources helps applicants find information on available jobs, provides consultation to managers and supervisors, informs current employees of benefits and services, and spearheads efforts to recruit hard-to-fill vacancies. OFFICE OF GOVERNMENT AFFAIRS: Office of Governmental Affairs is formerly the DHHS Office of Governmental Relations, the DHHS Office of Government Affairs collaborates with internal and external stakeholders to advance legislative policies and initiatives that promote the health, safety and well-being of North Carolinians. OFFICE OF COMMUNICATIONS: The Office of Communications works with the media to encourage public support for vulnerable populations. We alert the public to services they may need and to dangers to avoid. OFFICE OF GENERAL COUNSEL: The Office of General Counsel provides legal counsel to all Divisions and Offices within DHHS. Attorneys in the Office of General Counsel provide a broad spectrum of legal assistance including, but not limited to, addressing daily legal questions, TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A2-10

Page 11 of 13 Medicaid Administration assessing high-priority policy matters, and analyzing strategies for preventing or resolving litigation. The Office provides frequent legal counsel to DMA with respect to operation of the Medicaid program. OFFICE OF INFORMATION TECHNOLOGY: Formerly, called the Information Technology Division (ITD), this office provides technology services to the Department of Health and Human Services and interfaces with state agencies and other government customers across North Carolina. Services include hosting, network, telecommunications, desktop computing, project management services, and unified communications such as email and calendaring. Upload an organizational chart of the Medicaid agency. An attachment is submitted. Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies. The North Carolina Executive Branch is comprised of the following: • Governor’s Office • Cabinet Agencies, led by appointed officials • Office of the State Controller • Council of State Agencies, led by elected officials • Higher education (University and Community College systems) Outside of DHHS: • North Carolina Office of Administrative Hearings (OAH) – OAH makes final decision on beneficiary and provider contested cases. • Department of Public Instruction (DPI) – The Individual with Disabilities Education Act (IDEA) is the federal law requiring education related services to pre-school and school aged children with handicapping conditions. DMA works with DPI to provide Medicaid funding for those related services that are medically indicated, for example, speech, physical, and occupational therapy. Entities that determine eligibility other than the Medicaid Agency (if entities are described under Designation and Authority) Remove Type of entity that determines eligibility: Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. Pursuant to a 1634 agreement, the Social Security Administration determines Medicaid eligibility for Supplemental Security Income recipients. Add Entities that conduct fair hearings other than the Medicaid Agency (if are described under Designation and Authority) TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A2-11

Page 12 of 13 Medicaid Administration Remove Type of entity that conducts fair hearings: An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. Add Supervision of state plan administration by local political subdivisions (if described under Designation and Authority) Is the supervision of the administration done through a state-wide agency which uses local political subdivisions? Yes No The types of the local subdivisions that administer the state plan under the supervision of the Medicaid agency are: Counties Parishes Other Type of local subdivision: North Carolina’s 100 counties and the Boundary for the Federally Recognized Tribe, which encom Are all of the local subdivisions indicated above used to administer the state plan? Yes No Indicate the number used to administer the state plan: 101 Description of the staff and functions of the local subdivisions: The Federally Recognized Tribe and the Local County Departments of Social Services staff are responsible for the following: (A) Determining all individuals eligibility determinations for all eligibility groups under the state plan for North Carolina Medicaid and North Carolina Health Choice Programs (other than those determined by SSA). (B) Enrolling individuals in managed care programs. (C) Maintaining all individuals eligibility determination files. (D) Holding the initial evidentiary eligibility appeals for Medicaid/CHIP, unless the appeal is due to denial of disability, and providing hearing summary and evidence if applicant/beneficiary does not agree with local appeal decision. (E) The Qualla Boundary for the Eastern Band of Cherokee Indians encompasses parts of five of North Carolina’s 100 counties. The Medicaid agency has assigned an administrative code to the Qualla Boundary that will make it the one- hundredth and first local subdivision entity. (F) Individuals hired by the Federally Recognized Tribe to complete intake and eligibility determination activities meet the requirements in 42 CFR 431.10(c)(2), which restricts delegation of Medicaid eligibility and fair hearings activities to government agencies that maintain personnel standards on a merit basis. TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A2-12

Page 13 of 13 Medicaid Administration State Plan Administration Assurances A3 42 CFR 431.10 42 CFR 431.12 42 CFR 431.50 Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50. ✔ All requirements of 42 CFR 431.10 are met. ✔ There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12. ✔ The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters. ✔ Assurance for states that have delegated authority to determine eligibility: There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d). ✔ Assurances for states that have delegated authority to conduct fair hearings: There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d). When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency. Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings: The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis. ✔ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20141203 TN NO.: 16-0001-MM4 Approval Date: 02/23/17 Effective Date: 04/01/17 Supersedes NC-14-0001-MM4 North Carolina A3-13

Table of Contents

State/Territory Name: North Carolina State Plan Amendment (SPA) #: 19-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 61 Forsyth Street S.W. Suite 4T20 Atlanta, Georgia 30303

Atlanta Regional Operations Group

October 3, 2019

Mr. Dave Richard Deputy Secretary Division of Medical Assistance North Carolina Department of Health and Human Services 2501 Mail Service Center Raleigh, North Carolina 27699-2501

Dear Mr. Richard:

We have reviewed the proposed amendment to the North Carolina State Plan (SPA) NC 19-0008 which was submitted on August 30, 2019. This SPA was submitted to allow Medicaid to change the State Maximum Allowable rate for Community Support Team services due to a change in the service definition.

Based on the information provided, we have approved Medicaid State Plan Amendment NC 19-0008 on October 2, 2019. The effective date of this amendment is October 1, 2019.

Should you have questions or need further assistance, please contact Donald Graves at (919) 828-2999, or Charles Friedrich at (404) 562-7404.

Sincerely,

/s/

Davida R. Kimble

Acting Deputy Director

Division of Medicaid Field Operations South

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 FORM HCFA-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: 19-0008 2. STATE NC 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE October 1, 2019 5. TYPE OF PLAN MATERIAL (Check One):

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

42 CFR 438.6 (c) 7. FEDERAL BUDGET IMPACT: a. FFY 2020 $6, 376,161,00 b. FFY 2021 $7, 915,234,00

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 3.1-A1, pages 15a.6;15a.6a;15a.6b Attachment 4.19-B, Section 13; page 18.

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Attachment 3.1-A1, pages 15a.6;15a.6a; Attachment 4.19-B, Section 13, page 18.

10. SUBJECT OF AMENDMENT:

Community Support Team Service (CST) 11. GOVERNOR’S REVIEW (Check One):

GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: Secretary

COMMENTS OF GOVERNOR’S OFFICE ENCLOSED

NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: /s/ 16. RETURN TO:

Office of the Secretary Department of Health and Human Services 2001 Mail Service Center Raleigh, NC 27699-20014 13. TYPED NAME: Mandy Cohen, MD, MPH 14. TITLE: Secretary 15. DATE SUBMITTED: FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 08/30/19

18. DATE APPROVED: 10/02/19 PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 10/01/19 20. SIGNATURE OF REGIONAL OFFICIAL: /s/ 21. TYPED NAME: Davida R. Kimble

22. TITLE: Acting Deputy Director Division of Medicaid Field Operation 23. REMARKS: Approved with the following changes to block 8 and 9 as authorized by the state on email dated: 09/30/19

Block# 8 changed to read: Attachment 3.1-A. l pages 15a.6, and 15a.6a; Attachment 4.19-B Section 13 page 18

Block# 9 changed to read: Attachment 3.1-A.l pages 15a.6, and 15a.6a; Attachment 4.19-B Section 13 page 18

Attachment 3.1-A.1

; Page 15a.6 State Plan Under Title XIX of the Social Security Act

Medical Assistance Program State: NORTH CAROLINA

13. d. Diagnostic, Screening, Preventive, Treatment and Rehabilitative Services (continued,

Description of Services (vii) Community Support Team (CST) - (adults)

Services provided by this team consist of mental health and substance abuse services and supports necessary to assist adults in achieving rehabilitation and recovery goals. It assists individuals to gain access to necessary services; reduce psychiatric and addiction symptoms; and develop optimal community living skills. The services include assistance and support to individuals in crisis situation; service coordination; psycho education and support for individuals and their families: independent living skills; development of symptom monitoring and management skills, monitoring medications and self-medication,

This is an intensive community-based rehabilitation team service that provides direct treatment and restorative interventions.

individuals to gain access to necessary services to reduce psychiatric and addiction symptoms,

‘ance and support for individuals in crisis situations,

° — Service coordination,

e — Psycho-education,

¢ Individual restorative interventions for development of interpersonal, community coping and independent living skills; and

¢ Monitoring medications and self-medication.

The CST provider assumes the role of advocate, broker, coordinator and monitor of the service delivery system on the behalf of the recipient. The service must be ordered and prior approval will be required. A team must be comprised of four full-time staff positions as follows:

a. One full-time equivalent (FTE) dedicated Team Leader who is a licensed clinician. An associate level licensed clinician actively seeking licensure may serve as the Team Leader conditional upon being fully licensed within 30 calendar months from the effective date of hire.

b. One FTE dedicated team member who is a licensed substance abuse professional. Team member can be a Certified Clinical Supervisor (CCS), Licensed Clinical Addiction Specialist (LCAS), Licensed Clinical Addiction Specialist-Associate (LCAS-A), or a Certified Substance Abuse Counselor (CSAC).

¢. Two FTE team members that are Qualified Professionals, Associate Professionals, or Paraprofessionals or NC Certified Peer Support Specialist (NCCPSS).

All staff providing this service must have a minimum of one-year documented experience with the adult population. Clinical criteria are imbedded in the definition as well as service limitations to prevent duplication of services. It must be ordered by either, a physician, physician assistant, nurse practitioner or licensed psychologist. After December 31, 2010, this service can only be provided by and billed by a Critical Access Behavioral Health Care Agency (CABHA).

A beneficiary will be offered a choice of CST providers that include Certified Peer Support Specialist (CPSS) on the team if it is medically necessary that beneficiary have a CPSS.

Prior approval will be required.- This initial prior approval process will ensure that the level of the service is appropriate and concurrent reviews will determine the ongoing medical necessity for the service or the need to move up or down the continuum of services to another level of care.

Exclusions and limitations of CST are: © A beneficiary may receive CST services from only one CST provider organization during any active authorization period for this service. The beneficiary may choose a new provider at any time, which will initiate a new service authorization request and a new authorization period. ¢ CST may not be provided during the same authorization period as any other State Plan service that contains duplicative service components.

TN No.:_19-0008 Supersedes Approval Date: 10/02/19 Effective Date: 10/01/19 TN No.:_13-010

Attachment 3.1-A.1 Page |5a.6a State Plan Under Title XIX of the Social Security Act Medical Assistance Program

State: NORTH CAROLINA

13. d. Diagnostic, Screening, Preventive, Treatment and Rehabilitative Services (continued)

Description of Services

. The following are not billable under this service: © Transportation time (this is factored in the rate) o Any habilitation activities o Any social or recreational activities (or the supervision thereof) 9 Clinical and administrative supervision of staff (this is factored in the rate)

. Service delivery to individuals other than the beneficiary may be covered only when the activity is directed exclusively toward the benefit of that beneficiary. . CST services may be provided for bencficiaries residing in adult mental health residential facilities that are

16 beds or less: independent living; supervised living low or moderate: and group living low, moderate, or high. CST services may not be provided for beneficiaries residing in a nursing home facility. This service may not be provided to beneficiaries residing in Institutions for Mental Disease (IMD) regardless of the

facility type.

. CST services may be billed in accordance with the authorization for services during the same authorization period as Psychosocial Rehabilitation services based on medical necessity.

. For the purposes of helping a beneficiary transition to and from a service (facilitating an admission to a

service, discharge planning, or both) and ensuring that the service provider works dircctly with the CST Staff, CST services may be provided and billed for a maximum of 8 units for the first and last 30-day periods for beneficiaries who are authorized to receive the following service: o Assertive Community Tcam Treatment . For the purposes of helping a beneficiary transition to and from a service (facilitating an admission to a service, discharge planning, or both), providing coordination during the provision of a service, and ensuring that the service provider works directly with the CST Staff, CST services may be provided and billed for a maximum of eight units for each 30-day period for beneficiaries who are authorized to receive one of the following services: © — Substance Abuse Intensive Outpatient Program © Substance Abuse Comprehensive Outpatient Treatment . The provider of these services becomes responsible for the PCP and all other clinical home responsibilitics. ° For the purposes of helping a beneficiary transition to and from a service (facilitating an admission to a service, discharge planning, or both), providing coordination during the provision of a service, and ensuring that the service provider works directly with the CST Staff, CST services may be provided and billed in accordance with the authorization for services during the same authorization period for the following services based on medical necessity: o All detoxification services © Professional Treatment Services in Facility-Based Crisis Programs o Partial Hospitalization © Substance Abuse Medically Monitored Community Residential Treatment © Substance Abuse Non-Medically Monitored Community Residential Treatment . For beneficiaries under the age of 21, additional products, services, or procedures may be requested even if they do not appear in the N.C. State Plan or when coverage is limited to those over 21 years of age. Service limitations on scope, amount, or frequency described in the coverage policy may not apply if the product, service, or procedure is medically necessary. NOTE: This service is used as an intervention to avoid need for a higher level of care or as a step down from a higher level of care. It is an ACTT “lite” service.

TN No.:_19-0008 Supersedes Approval Date: 10/02/1 Effective Date: 10/01/19 TN No.:_13-010

Attachment 4.19-B Section 13, Page 18

MEDICAL ASSISTANCE State: North Carolina

PAYMENTS FOR MEDICAL AND REMEDIAL CARE AND SERVICE

18) Community Support Team (H2015HT)

Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of Community Support Team. The rate has changed and is effective as of October 1, 2019 for services provided on or after that date. The rate will be billed in increments of 15 minutes. The rate was derived based on required staffing direct labor and employment costs, overhead and associated program expenses. All rates are on the agency’s fee schedule which is published on the agency’s website at https://medicaid.ncdhhs.gov/providers/ fee-schedulevenha nced-mental-health-services-fee-schedule.

This service will be provided by direct enrolled Medicaid providers who may be either private or governmental. This service is not cost settled for any provider. This service is provided in accordance with Attachment 3.1- A.1 Page 15a.6, Paragraph 13.d., subparagraph (vii).

The facilities providing this service are not IMD facilities and NC Medicaid is not reimbursing room and board for this service.

TN No: 19-0008 Supersedes Approval Date: 10/02/19 Effective Date: 10/01/19 TN No: 14-032

Table of Contents State/Territory Name: North Carolina State Plan Amendment (SPA) #: 20-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 May 1, 2020 Mr. Dave Richard Deputy Secretary Division of Medical Assistance North Carolina Department of Health and Human Services 2501 Mail Service Center Raleigh, North Carolina 27699-2501 Re: North Carolina State Plan Amendment (SPA) 20-0008 Dear Mr. Richard: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0008. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. 3XUVXDQW WR VHFWLRQ  E

 RI WKH $FW IRU WKH SHULRG RI WKH SXEOLF KHDOWK HPHUJHQF\ &06 LV PRGLI\LQJ WKH UHTXLUHPHQW DW  &)5  WKDW WKH VWDWH VXEPLW 63$V UHODWHG WR WKH &29,' SXEOLF KHDOWK HPHUJHQF\ E\ WKH ILQDO GD\ RI WKH TXDUWHU WR REWDLQ D 63$ HIIHFWLYH GDWH GXULQJ WKH TXDUWHU HQDEOLQJ 63$V VXEPLWWHG DIWHU WKH ODVW GD\ RI WKH TXDUWHU WR KDYH DQ HIIHFWLYH GDWH LQ D SUHYLRXV TXDUWHU EXW QR HDUOLHU WKDQ WKH HIIHFWLYH GDWH RI WKH SXEOLF KHDOWK HPHUJHQF\

7KH 6WDWH RI 1RUWK &DUROLQD DOVR UHTXHVWHG D ZDLYHU RI SXEOLF QRWLFH UHTXLUHPHQWV DSSOLFDEOH WR WKH 63$ VXEPLVVLRQ SURFHVV 3XUVXDQW WR VHFWLRQ  E



& RI WKH $FW &06 LV ZDLYLQJ SXEOLF QRWLFH UHTXLUHPHQWV DSSOLFDEOH WR WKH 63$ VXEPLVVLRQ SURFHVV 3XEOLF QRWLFH IRU 63$V LV UHTXLUHG XQGHU  &)5 † IRU FKDQJHV LQ VWDWHZLGH PHWKRGV DQG VWDQGDUGV IRU VHWWLQJ 0HGLFDLG SD\PHQW UDWHV  &)5 † IRU FKDQJHV WR SUHPLXPV DQG FRVW VKDULQJ DQG  &)5 † IRU FKDQJHV WR $OWHUQDWLYH %HQHILW 3ODQV $%3V  3XUVXDQW WR VHFWLRQ  E



&  &06 LV DSSURYLQJ WKH VWDWH¶V UHTXHVW WR ZDLYH WKHVH QRWLFH UHTXLUHPHQWV RWKHUZLVH DSSOLFDEOH WR 63$ VXEPLVVLRQV The State of North Carolina also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Under section 1135(b)(5) of the Act, CMS is also approving the State of North Carolina’s request for flexibility to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. 7KHVH ZDLYHUV RU PRGLILFDWLRQV RI WKH UHTXLUHPHQWV UHODWHG WR 63$ VXEPLVVLRQ WLPHOLQHV SXEOLF QRWLFH DQG WULEDO FRQVXOWDWLRQ DSSO\ RQO\ ZLWK UHVSHFW WR 63$V WKDW PHHW WKH IROORZLQJ FULWHULD

 WKH 63$ SURYLGHV RU LQFUHDVHV EHQHILFLDU\ DFFHVV WR LWHPV DQG VHUYLFHV UHODWHG WR &29,'

VXFK DV E\ ZDLYLQJ RU HOLPLQDWLQJ FRVW VKDULQJ LQFUHDVLQJ SD\PHQW UDWHV RU DPHQGLQJ $%3V WR DGG VHUYLFHV RU SURYLGHUV

 WKH 63$ GRHV QRW UHVWULFW RU OLPLW SD\PHQW RU VHUYLFHV RU RWKHUZLVH EXUGHQ EHQHILFLDULHV DQG SURYLGHUV DQG  WKH 63$ LV WHPSRUDU\ ZLWK D VSHFLILHG VXQVHW GDWH WKDW LV QRW ODWHU WKDQ WKH ODVW GD\ RI WKH GHFODUHG &29,' SXEOLF KHDOWK HPHUJHQF\ RU DQ\ H[WHQVLRQ WKHUHRI  :H QRQHWKHOHVV HQFRXUDJH VWDWHV WR PDNH DOO UHOHYDQW LQIRUPDWLRQ DERXW WKH 63$ DYDLODEOH WR WKH SXEOLF VR WKH\ DUH DZDUH RI WKH FKDQJHV We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that North Carolina’s Medicaid SPA Transmittal Number 20-0008 is approved effective March 1, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Charles Friedrich at (404) 562-7404 or by email at Charles.Friedrich@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of North Carolina and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.05.18 09:53:43 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE 20-0008 NC

STATE PLAN MATERIAL

FOR: HEALTH CARE FINANCING ADMINISTRATION

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

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

4. PROPOSED EFFECTIVE DATE March 1, 2020

5. TYPE OF PLAN MATERIAL (Check One):

[_] NEW STATE PLAN

[_] AMENDMENT TO BE CONSIDERED AS NEW PLAN

[><] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: Sections 201/301 National Emergencies Act Sec. 1135(b) Social Security Act

7. FEDERAL BUDGET IMPACT: a. FFY 2020 $107,000,000 b. FFY 2021 $5,000,000

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Section 7.4 Medicaid Disaster Relief SPA Template Pages 89a - 89j

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

NEW

10. SUBJECT OF AMENDMENT:

Medicaid Disaster Relief

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

XX] OTHER, AS SPECIFIED: Secretary

12. SIGNATURE OF STATE AGENCY OFFICIAL:

13. TYPED NAME: Mandy Cohen, MD, MPH

14. TITLE: Secretary

15. DATE SUBMITTED: April 17, 2020

16. RETURN TO:

Office of the Secretary

Department of Health and Human Services 2001 Mail Service Center

Raleigh, NC 27699-20014

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

18. DATE APPROVED:

04/09/20 5/18/20 PLAN APPROVED — ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIG ATURE QE. REGIOD AL KELGIAL: ine M. Costello -S s

03/01/20

(Date 2020.05.18 0954 13-000"

21. TYPED NAME: Anne Marie Costello

22. TITLE: Deputy Director, CMCS

23. REMARKS:

North Carolina concurrence of Pen-and-Ink change to Disaster SPA template for Section C-Premiums and Cost Sharing language to incorporate: “The state waives cost-sharing for testing services (including in vitro diagnostic products), testing-related services, and treatments for COVID-19, including vaccines, specialized equipment and therapies (including drugs), for any quarter in which the temporary increased FMAP is claimed."

FORM HCFA-179 (07-92)

State/Territory: North Carolina Disaster SPA #1 89a TN: 20-0008 Supersedes TN: ____NEW____ Approval Date: 05/1ϴ/20 Effective Date: 03/01/20 Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: N/A NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 __X___ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. ___X__ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. ___X__ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates).

State/Territory: North Carolina Disaster SPA #1 89b TN: 20-0008 Supersedes TN: ____NEW____ Approval Date: 05/1ϴ/20 Effective Date: 03/01/20 c. __X___ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in the North Carolina Medicaid state plan, as described below: Medicaid will notify the Tribe of all SPA changes on or before submission to CMS, and offer a telephonic meeting to discuss. Section A – Eligibility 1. _____ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. Include name of the optional eligibility group and applicable income and resource standard. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ -or-

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

State/Territory: North Carolina Disaster SPA #1 89c TN: 20-0008 Supersedes TN: ____NEW____ Approval Date: 05/1ϴ/20 Effective Date: 03/01/20 Less restrictive resource methodologies: 4. _____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: 6. _____ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. _____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Please describe any limitations related to the populations included or the number of allowable PE periods.

State/Territory: North Carolina Disaster SPA #1 89d TN: 20-0008 Supersedes TN: ____NEW____ Approval Date: 05/1ϴ/20 Effective Date: 03/01/20 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. __X___ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: The State waives cost-sharing for testing services (including in vitro diagnostic products), testing- related services, and treatments for COVID-19, including vaccines, specialized equipment and therapies (including drugs), for any quarter in which the temporary increased FMAP is claimed. 2. __X___ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. __X___ The following eligibility groups or categorical populations: