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us-nc/policy/cms/medicaid-state-plan/spa — Axiom

(nc-09-017)(attachment)(page-1)Page 1#

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

(nc-09-017)(attachment)(page-2)Page 2#

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

(nc-09-017)(attachment)(page-5)Page 5#

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

(nc-09-017)(attachment)(page-6)Page 6#

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

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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

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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

(nc-09-017)(attachment)(page-9)Page 9#

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

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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

(nc-09-017)(attachment)(page-11)Page 11#

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.

______________________________________________________________________________________ TN No.: 09-017 Supersedes

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

(nc-09-017)(attachment)(page-12)Page 12#

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

(nc-09-017)(attachment)(page-13)Page 13#

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 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

(nc-09-017)(attachment)(page-14)Page 14#

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

(nc-09-017)(attachment)(page-15)Page 15#

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

(nc-09-017)(form-cms-179)(page-1)Page 1#

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)

(nc-13-004)(attachment)(page-1)Page 1#

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

(nc-13-013)(approval-document)(page-4)Page 4#

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

(nc-13-0014-mm1)(approval-document)(page-9)Page 9#

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

(nc-13-0014-mm1)(approval-document)(page-10)Page 10#

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.

[®] Presumptive Eligibility

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

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

(nc-13-0014-mm1)(approval-document)(page-18)Page 18#

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

(nc-13-0014-mm1)(approval-document)(page-19)Page 19#

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

(nc-13-0014-mm1)(approval-document)(page-22)Page 22#

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

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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

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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

(nc-13-0014-mm1)(approval-document)(page-26)Page 26#

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

(nc-13-0014-mm1)(approval-document)(page-27)Page 27#

Medicaid Eligibility

’ 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

(nc-13-0014-mm1)(approval-document)(page-28)Page 28#

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

(nc-13-0014-mm1)(approval-document)(page-30)Page 30#

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

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

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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\

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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.

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.

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

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

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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.

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.

[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.

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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.

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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'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.

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Medicaid Eligibility

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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

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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.

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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;

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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).

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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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@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:

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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.

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

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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.

@ 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'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.

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bene eee

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Ss Medicaid Eligibility

“ETE 708 EONAR A CCAD Se

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.

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

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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

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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

@ 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'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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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

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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

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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\

(nc-20-0008)(approval-document)(page-3)Page 3#

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'

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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)

(nc-20-0008)(approval-document)(page-5)Page 5#

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).

(nc-20-0008)(approval-document)(page-7)Page 7#

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.

(nc-20-0008)(approval-document)(page-8)Page 8#

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:

(nc-20-0008)(approval-document)(page-13)Page 13#

State/Territory: North Carolina Disaster SPA #1 89i TN: 20-0008 Supersedes TN: ____NEW____ Approval Date: 05/1ϴ/20 Effective Date: 03/01/20 ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. __X___ Other payment changes: Please describe. For the duration of the public health emergency, any Medicaid-enrolled provider may request that its reimbursement be converted to an interim payment methodology. Under the interim payment methodology, the requesting provider will receive an amount equal to two months’ payment at the historical average monthly Medicaid payment, based on the months of January and February 2020. Critical access hospitals would be eligible to receive up to 125% of the historical payment amount. The State will subsequently reconcile the interim payments with final payments that the provider is eligible for based on billed claims. After reconciliation, payments will be equal to the actual utilization during the period at current Medicaid rates. NC has indicated that reconciliation would occur following implementation of the rate adjustment in our MMIS using our normal recoupment process. The provider recoupment process could begin as early as July 2020. Federal share on interim payments will be returned to CMS on quarterly CMS-64 reports. Section F – Post-Eligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups.

(nc-20-0009)(approval-document)(page-2)Page 2#

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 August , 2020 Mr. Dave Richard Deputy Secretary, North Carolina Medicaid Division of Health Benefits NC Department of Health and Human Services 1985 Umstead Drive 2501 Mail Service Center Raleigh, North Carolina 27699-2501 Re: North Carolina State Plan Amendment (SPA) 20-0009 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) 20-0009. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during

(nc-20-0009)(approval-document)(page-3)Page 3#

the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency. The State of North Carolina requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is also waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions. The State of North Carolina also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These waivers or modifications of the requirements related to SPA submission timelines, public notice, and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that North Carolina’s Medicaid SPA Transmittal Number 20-0009 is approved effective March 1, 2020. 3OHDVH QRWH WKDW WKH HIIHFWLYH GDWHV IRU FHUWDLQ SD\PHQW SURYLVLRQV GHVFULEHG LQ 6HFWLRQV ( DQG ( DUH HLWKHU $SULO RU 0DUFK This SPA approval is in addition to the North Carolina Disaster Relief SPA approved on May 18, 2020, and does not supersede anything approved in that SPA. (QFORVHG LV D FRS\ RI WKH &06 VXPPDU\ IRUP DQG WKH DSSURYHG VWDWH SODQ SDJHV 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 FDUH FRPPXQLW\ Enclosures 6LQFHUHO\ $OLVVD 0RRQH\ 'H%R\ 'LUHFWRU 'LVDEOHG DQG (OGHUO\ +HDOWK 3URJUDPV *URXS RQ EHKDOI RI $QQH 0DULH &RVWHOOR $FWLQJ 'LUHFWRU &HQWHU IRU 0HGLFDLG &+,3 6HUYLFHV Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2020 08.18 08:47:17 -04'00'

(nc-20-0009)(approval-document)(page-4)Page 4#

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 20-0009 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

x] AMENDMENT

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

6. FEDERAL STATUTE/REGULATION CITATION: Title 19 of the Social Security Act Sec. 1135(b) Social Security Act

7. FEDERAL BUDGET IMPACT: a. FFY 2020 $248.087.531 b. FFY 2021 $10,688,877

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

7.4 Medicaid Disaster Relief SPA Template Pages 89k-89t

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

10. SUBJECT OF AMENDMENT:

Medicaid Disaster Relief Round 2

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

[><] OTHER, AS SPECIFIED: Secretary

12. SIGNATURE OF STATE AGENCY OFFICIAL:

13. TYPED NAME: Mandy Cohen, MD, MPH

14, TITLE: Secretary

15. DATE SUBMITTED: May 27, 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: 5/27/20

18. DATE APPROVED: 08/18/2020

PLAN APPROVED — ONE COPY ATTACHED wm n

19. EFFECTIVE DATE OF APPROVED MATERIAL: 3/01/20

20. SIGNATURE OF REGIONAT M. Deboy -S eboy -Sosarss-or00"

21. TYPED NAME: Alissa Mooney DeBoy

22. TITLE: Director, DEHPG, on behalf of Acting Director, CMCS

23. REMARKS:

Pen-n-Ink concurrence received from NC to remove unneeded language from Section D-Benefits of the template; as well as adding effective dates and clarifying language to Section E — Payments.

FORM HCFA-179 (07-92)

(nc-20-0009)(approval-document)(page-5)Page 5#

State/Territory: North Carolina Disaster SPA #2 TN: ___20Ͳ0009___________ Supersedes TN: ___NEW_____________ Approval Date: ϬϴͬϭϴͬϮϬ Effective Date: 03/01/20 This SPA is in addition to the NC Disaster Relief SPA #1 approved on 5/18/20, and does not supersede anything approved in that SPA. Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVIDͲ19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVIDͲ19 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 COVIDͲ19 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 COVIDͲ19 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 COVIDͲ19 outbreak (or any renewals thereof), or for any shorter period described below: Effective April 1, 2020, an additional 10% (additional to a previous COVID SPA that granted a 5% increase) rate increase for Skilled Nursing Facilities, PCS providers (Adult Care Homes and InͲHome), Home Health Providers, Veteran Home Nursing Facilities, and the Tsali Tribal Skilled Nursing Facility. &Žƌ ĂƚĞƐ ŽĨ ^ĞƌǀŝĐĞ DĂƌĐŚ ϭϬ͕ ϮϬϮϬ ƚŽ DĂƌĐŚ ϯϭ͕ ϮϬϮϬ͕ ŝŶĐůƵƐŝǀĞ͕ ƚĞůĞƉŚŽŶĞ ƐĞƌǀŝĐĞƐ ďŝůůĂďůĞ ƵŶĚĞƌ 'ϬϬϳϭ ďǇ ĂŶ &Y,ͬZ, ǁŝůů ďĞ ƉĂŝĚ Ăƚ ĂŶ ĂŵŽƵŶƚ ĞƋƵĂů ƚŽ ƚŚĞ &Y,ͬZ, WW^ ƌĂƚĞ͘ 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 WĂŐĞ ϴϵŬ

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(nc-20-0009)(approval-document)(page-7)Page 7#

State/Territory: North Carolina Disaster SPA #2 TN: ___20Ͳ0009________ Supersedes TN: ___NEW_________ Approval Date: ϬϴͬϭϴͬϮϬ Effective Date: 03/01/20 This SPA is in addition to the NC Disaster Relief SPA #1 approved on 5/18/20, and does not supersede anything approved in that SPA. 6. __X__ The agency provides for an extension of the reasonable opportunity period for nonͲ citizens declaring to be in a satisfactory immigration status, if the nonͲcitizen 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 90Ͳday reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. ____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. 2. ____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. 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 MAGIͲ 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 callͲcenters or other telephone applications in affected areas. WĂŐĞ ϴϵŵ

(nc-20-0009)(approval-document)(page-8)Page 8#

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State/Territory: North Carolina Disaster SPA #2 TN: ___20Ͳ0009___________ Supersedes TN: ___NEW_____________ Approval Date: ϬϴͬϭϴͬϮϬ Effective Date: 03/01/20 This SPA is in addition to the NC Disaster Relief SPA #1 approved on 5/18/20, and does not supersede anything approved in that SPA. beneficiaries transitioning to/from certain other services and allow for 40 units. (Attachment 3.1ͲA.1 Page 15a.6Ͳ6a) i) Suspend Assertive Community Treatment Team (ACTT) requirements for team composition if staff sick/unavailable. Suspend staff/bene ratio. Suspend fidelity to the model. (Attachment 3.1Ͳ A.1 Page 15a.7) j) Suspend minimum hours per day for Psychosocial Rehabilitation. Suspend staff ratio if telephonic Ͳ not if facility. (Attachment 3.1ͲA.1 Pages 15a.3Ͳ3a) k) Suspend Partial Hospitalization minimum per day Ͳ must have 10 hours per week. (Attachment 3.1ͲA.1 Page 7c.5) l) Suspend minimum hours per day to 1.5hrs/day, 3 days per week for Substance Abuse Intensive Outpatient Program. Suspend staff ratio. Suspend the requirement that CCS or LCAS are on site 50% of the hours they are open and instead be available telephonically. Suspend the requirement that services must be done in facility. Suspend Urinalysis Drug Screenings. (Attachment 3.1ͲA.1 Page 7c.8) m) For Substance Abuse Comprehensive Outpatient Treatment, reduce minimum to 2 hours per day, 5 days per week. Suspend Urinalysis Drug Screenings. (Attachment 3.1ͲA.1 Page 15a.10) n) For Substance Abuse NonͲMedical Community Residential Treatment, suspend more than 30 days in 12 months. (Attachment 3.1ͲA.1 Page 15a.11) o) For Substance Abuse Medically Monitored Community Residential Treatment, suspend more than 30 days in 12 months. (Attachment 3.1ͲA.1 Page 15a.11ͲA) p) NonͲHospital Medical Detoxification. Suspend more than 30 days in 12 months. (Attachment 3.1ͲA.1 Page 15a.12ͲA). q) Suspend staff training requirements for Therapeutic Foster Care. (Attachment 3.1ͲA Pages 15a.18dͲ35) r) For Residential Level IV, suspend parent and legal guardian must participate in rehabilitation plan development and implementation if unavailable due to illness. Suspend opportunity for beneficiary inclusion in community activities. Suspend training except for sex offenderͲspecific training. (Attachment 3.1ͲA Pages 15a.18dͲ35) s) Suspend TL limits Ͳ up to 90 days for Therapeutic Leave for Psychiatric Residential Treatment Facilities (PRTF) and Levels IIͲIV Residential Facilities. (Attachment 4.19ͲC Page 2) t) Suspend TL limits Ͳ up to 120 days for Therapeutic Leave for Nursing Facilities and Intermediate Care for the Mentally Retarded (ICFͲMR). (Attachment 4.19ͲC Page 1) u) Suspend 30Ͳday max with PA for Professional Treatment Services in FacilityͲBased Crisis Program. (Attachment 3.1ͲA.1 Pages 7c.9aͲ9e) v) Suspend 30Ͳday max with PA for FacilityͲBased Crisis Programs (FBC) (Attachment 3.1ͲA.1 Pages 7c.9aͲ9e) w) Suspend 30Ͳday max within 12 months for Medically Supervised or ADATC Detoxification Crisis Stabilization. (Attachment 3.1ͲA.1 Page 15a.13) 3. __X___ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). WĂŐĞ ϴϵŽ

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State/Territory: North Carolina Disaster SPA #2 TN: ___20Ͳ0009___________ Supersedes TN: ___NEW_____________ Approval Date: ϬϴͬϭϴͬϮϬ Effective Date: 03/01/20 This SPA is in addition to the NC Disaster Relief SPA #1 approved on 5/18/20, and does not supersede anything approved in that SPA. Other: 4. __X___ Other payment changes: &Žƌ ƚĞůĞƉŚŽŶĞ ƐĞƌǀŝĐĞƐ ďŝůůĂďůĞ ƵŶĚĞƌ 'ϬϬϳϭ ďǇ ĂŶ &Y,ͬZ,͕ ĨŽƌ ƚŚĞ ĚĂƚĞƐ ŽĨ ƐĞƌǀŝĐĞ DĂƌĐŚ ϭϬ͕ ϮϬϮϬ ƚŚƌŽƵŐŚ DĂƌĐŚ ϯϭ͕ ϮϬϮϬ͕ ŝŶĐůƵƐŝǀĞ͕ &Y,ƐͬZ,Ɛ ǁŝůů ďĞ ƉĂŝĚ Ăƚ ĂŶ ĂŵŽƵŶƚ ĞƋƵĂů ƚŽ ƚŚĞ &Y,ͬZ, WW^ ƌĂƚĞ ;ĂŶ ŝŶĐƌĞĂƐĞ ĨƌŽŵ ƚŚĞ ƌĂƚĞ ĂƉƉƌŽǀĞĚ ŝŶ ^WͲEͲϮϬͲϬϬϬϴͿ͘ &Žƌ ƐĞƌǀŝĐĞƐ ĨƌŽŵ DĂƌĐŚ ϭ͕ ϮϬϮϬ ƚŽ DĂƌĐŚ ϵ͕ ϮϬϮϬ ĂŶĚ ĨƌŽŵ Ɖƌŝů ϭ͕ ϮϬϮϬ ƚŚƌŽƵŐŚ ƚŚĞ ĞŶĚ ŽĨ ƚŚĞ W, ͕ ƚĞůĞƉŚŽŶĞ ƐĞƌǀŝĐĞƐ ďŝůůĂďůĞ ƵŶĚĞƌ 'ϬϬϳϭ ďǇ ĂŶ &Y,ͬZ, ǁŝůů ďĞ ƉĂŝĚ Ăƚ ƚŚĞ ƐĂŵĞ ƌĂƚĞ ĂƐ ĂƉƉƌŽǀĞĚ ŝŶ ^WͲ EͲϮϬͲϬϬϬϴ͕ ǁŚŝĐŚ ŝƐ ĂŶ ĂŵŽƵŶƚ ĞƋƵĂů ƚŽ ϴϬй ŽĨ ƚŚĞ ƐƚĂŶĚĂƌĚ ΘD ƌĂƚĞ͘ WƌŝŽƌ ƚŽ ƚŚĞ ƉƵďůŝĐ ŚĞĂůƚŚ ĞŵĞƌŐĞŶĐǇ͕ ƚŚĞ &Y,Ɛ ĂŶĚ Z,Ɛ ǁĞƌĞ ŶŽƚ ĂůůŽǁĞĚ ƚŽ ƉƌŽǀŝĚĞ ƚĞůĞƉŚŽŶŝĐ Žƌ ƚĞůĞŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ĂƐ ĚŝƐƚĂŶƚ ƐŝƚĞƐ ĨŽƌ E DĞĚŝĐĂŝĚ ;Žƌ DĞĚŝĐĂƌĞͿ ďĞŶĞĨŝĐŝĂƌŝĞƐ͘ &Žƌ ƚŚŝƐ ƌĞĂƐŽŶ͕ ƚŚĞŝƌ ƐǇƐƚĞŵƐ ǁĞƌĞ ŶŽƚ Ăƚ Ăůů ĚĞǀĞůŽƉĞĚ ƚŽ ƉƌŽǀŝĚĞ ƌĂƉŝĚ ƚĞůĞŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ͘ dŽ ŵĂŝŶƚĂŝŶ DĞĚŝĐĂŝĚ ďĞŶĞĨŝĐŝĂƌǇ͛Ɛ ĂĐĐĞƐƐ ƚŽ ĐĂƌĞ ŝŶ ƚŚĞ ŵŝĚƐƚ ŽĨ ƐŽĐŝĂů ĚŝƐƚĂŶĐŝŶŐ͕ ƚŚĞ ƐƚĂƚĞ ĂƵƚŚŽƌŝǌĞĚ Ăůů ƉƌŝŵĂƌǇ ŚĞĂůƚŚ ĐĂƌĞ ƉƌŽǀŝĚĞƌƐ͕ ŝŶĐůƵĚŝŶŐ &Y,Ɛ ĂŶĚ Z,Ɛ͕ ƚŽ ĐŽŶĚƵĐƚ ƚĞůĞƉŚŽŶŝĐ ĂŶĚ ƚĞůĞŚĞĂůƚŚ ǀŝƐŝƚƐ͘ dĞůĞŚĞĂůƚŚ ǀŝƐŝƚƐ ǁŽƵůĚ ďĞ ƉĂŝĚ Ăƚ ƉĂƌŝƚǇ ǁŝƚŚ ŽĨĨŝĐĞ ǀŝƐŝƚƐ ;ĨŽƌ &Y,Ɛ ĂŶĚ Z,Ɛ͕ ƚĞůĞŚĞĂůƚŚ ǁŽƵůĚ ďĞ ĐŽŶƐŝĚĞƌĞĚ ĂŶ ĞŶĐŽƵŶƚĞƌͿ͕ ǁŚŝůĞ ƚĞůĞƉŚŽŶŝĐ ƐĞƌǀŝĐĞƐ ďŝůůĂďůĞ ƵŶĚĞƌ 'ϬϬϳϭ ďǇ &Y,Ɛ ĂŶĚ Z,Ɛ ǁŽƵůĚ ďĞ ƉĂŝĚ Ăƚ ϴϬй ŽĨ Ă ƐƚĂŶĚĂƌĚ ĨĂĐĞͲƚŽͲĨĂĐĞ ǀĂůƵĂƚŝŽŶ Θ DĂŶĂŐĞŵĞŶƚ ; ΘDͿ ŽĨĨŝĐĞ ǀŝƐŝƚ ;ĂƐ ĚĞƐĐƌŝďĞĚ ŝŶ ^WͲEͲϮϬͲϬϬϬϴͿ͕ ǁŝƚŚ ƚŚĞ ĞǆĐĞƉƚŝŽŶ ŽĨ ƚŚĞ ƉĞƌŝŽĚ ŽĨ DĂƌĐŚ ϭϬ ƚŽ DĂƌĐŚ ϯϭ͕ ϮϬϮϬ ;ĂƐ ĚĞƐĐƌŝďĞĚ ŝŶ ƚŚĞ ƉƌĞĐĞĚŝŶŐ ƉĂƌĂŐƌĂƉŚͿ͘ For Therapeutic Leave for Psychiatric Residential Treatment Facilities (PRTF), reimburse when the patient is hospitalized as well as when they are absent from the facility at their family's home. (Attachment 4.19ͲC Page 2). See Benefits section Item s. For Therapeutic Leave for Nursing Facilities and Intermediate Care for the Mentally Retarded (ICFͲMR), reimburse when the patient is hospitalized as well as when they are absent from the facility at their family's home. (Attachment 4.19ͲC Page 1). See Benefits section Item t. Section F – PostͲEligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: WĂŐĞ ϴϵƐ

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DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL I. TRANSMITTAL NUMBER: 21~0022 3. PROGRAM IDENTIFICATION: FORM APPROVED 0MB 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 July 1, 2021 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [21 AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate Transmittal or each amendment 7. FEDERAL BUDGET IMPACT: 1916 and 1916A l93i!(a)(l)(A) of the Social Security Act a. FFY 2021 $0.00 b. FFY 2022 $0.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Meeteate PremtllfflS Gest Shl!Mg Medicaid Premiums Cost Sharing Templates GI - G3 (New) Templates Cl €3 ~ Jen) Section4.18, Page 54, 55, 56, 56a, 56b, 56c, 56d, 56e, 56f; Attachment 4.18-A, Page 1,3; Attachment 4. 18-C, Page 1,3 10. SUBJECT OF AMENDMENT: Medicaid Premium Cost Sharing 11. GOVERNOR'S REVIEW (Check One) : 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED [21 OTHER, AS SPECIFIED: Secretary 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: //4 .4,-"/C:::::/ / Office of the Secretary - l 3 ___ T_YP_E_D_N_A_ME --: -------------------1 Department of Health and Human Services Mand Cohen MD MPH 2001 Mail Service Center __ ....;._..;......;;..;;...;..;......;...__,_ ______________ ----I 14. TITLE: Raleigh, NC 27699-20014 Secreta 15. DATE SUBMITTED: 9/29/2021 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: September 29, 2021 18. DATE APPROVED: December 28, 2021 PLAN APPROVED - ONE COPY A TT ACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: July l , 2021 20. SIGN • II 11 I 1 GIONAL OFFICIAL: Digitally signed byJamesG. Scott-S 21. TYPED NAME: 23. REMARKS: , OatP'20211229J3·J0·J6:96'00' James G. Scott . 22. TITL Director, Division of Program Operations Pen and ink change authorized in box 6 and box 9 on 12/20/21 and 12/29/21 to add correct statutory regulation and appropriate superseding pages. FORM HCFA-179 (07-92)

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Medicaid Premiums and Cost Sharing State Name:INorth Carolina Transmittal Number: NC - 21 - 0022 0MB Control Number: 0938-1148 Cost Sharing Requirements 1916 1916A 42 CFR 447.50 through 447.57 (excluding 447.55) The state charges cost sharing ( deductibles, co-insurance or co-payments) to individuals covered under Medicaid. ~The state assures that it administers cost sharing in accordance with sections 1916 and 1916A of the Social Security Act and 42 CFR 447.50 through 447.57. General Provisions ~ The cost sharing amounts established by the state for services are always less than the amount the agency pays for the service. I!: No provider may deny services to an eligible individual on account of the individual's inability to pay cost sharing, except as elected by the state in accordance with 42 CFR 447.52(e)(l). I!: The process used by the state to inform providers whether cost sharing for a specific item or service may be imposed on a beneficiary and whether the provider may require the beneficiary to pay the cost sharing charge, as a condition for receiving the item or service, is (check all that apply): 0 The state includes an indicator in the Medicaid Management Information System (MMIS) C The state includes an indicator in the Eligibility and Enrollment System C The state includes an indicator in the Eligibility Verification System C The state includes an indicator on the Medicaid card, which the beneficiary presents to the provider C Other process I!: Contracts with managed care organizations (MCOs) provide that any cost-sharing charges the MCO imposes on Medicaid enrollees are in accordance with the cost sharing specified in the state plan and the requirements set forth in 42 CFR 447.50 through 447.57. Cost Sharing for Non-Emergency Services Provided in a Hospital Emergency Department The state imposes cost sharing for non-emergency services provided in a hospital emergency department. ~ The state ensures that before providing non-emergency services and imposing cost sharing for such services, that the hospitals providing care: I!: Conduct an appropriate medical screening under 42 CFR 489.24, subpart G to determine that the individual does not need emergency services; I!: Inform the individual of the amount of his or her cost sharing obligation for non-emergency services provided in the emergency department; I!: Provide the individual with the name and location of an available and accessible alternative non-emergency services provider; Transmittal Number. NC 21-0022 Pa2:e 1 of2 Approval Date: December 28, 202'1 Effective Date: July 1, 2021

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Medicaid Premiums and Cost Sharing [i Determine that the alternative provider can provide services to the individual in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing if the individual is otherwise exempt from cost sharing; and 0C Provide a referral to coordinate scheduling for treatment by the alternative provider. ~ The state assures that it has a process in place to identify hospital emergency department services as non-emergency for purposes of imposing cost sharing. This process does not limit a hospital's obligations for screening and stabilizing treatment of an emergency medical condition under section 1867 of the Act; or modify any obligations under either state or federal standards relating to the application of a prudent-layperson standard for payment or coverage of emergency medical services by any managed care organization. The process for identifying emergency department services as non-emergency for purposes of imposing cost sharing is: The state maintains a list of codes that will be periodically updated. Cost Sharing for Drugs The state charges cost sharing for drugs. The state has established differential cost sharing for preferred and non-preferred drugs. 0C All drugs will be considered preferred drugs. Beneficiary and Public Notice Requirements ~ Consistent with 42 CFR 447.57, the state makes available a public schedule describing current cost sharing requirements in a manner that ensures that affected applicants, beneficiaries and providers are likely to have access to the notice. Prior to submitting a SP A which establishes or substantially modifies existing cost sharing amounts or policies, the state provides the public with advance notice of the SP A, specifying the amount of cost sharing and who is subject to the charges, and provides reasonable opportunity for stakeholder comment. Documentation demonstrating that the notice requirements have been met are submitted with the SP A. The state also provides opportunity for additional public notice if cost sharing is substantially modified during the SPA approval process. Other Relevant Information The State has copayments for covered Outpatient Pharmacy medications for adults (21 and older) in the traditional Medicaid program. Those copayments are $3 per prescription. Children(< age 21), pregnant women, members in hospice, Tribal members, NC BCCCP members, children in foster care, and people in institutions in the traditional Medicaid program have $0 copayment for all prescriptions. 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 0MB control number. The valid 0MB 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. Transmittal Number: NC 21-0022 V.20160722 Pa2:e 2 of2 Approval Date: December 28, 202'1 Effective Date: July 1, 2021

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Medicaid Premiums and Cost Sharing State Name:INorth Carolina Transmittal Number: NC - 21 - 0022 0MB Control Number: 0938-1148 Cost Sharing Amounts - Targeting G2c 1916 1916A 42 CFR 447.52 through 54 The state targets cost sharing to a specific group or groups of individuals. ~ I Population Name (optional): I Eligibility Group(s) Included: !All Eligibility Groups With Exception ofBCCM Beneficiaries Incomes Greater than I ol TO Incomes Less than or Equal to I 250%FPLI Dollars or Add Service Amount Percentage Unit Explanation Remove Add Physician, Outpatient, Podiatrists 3.00 $ Visit Reduce over-utilization Remove Add Generic and Brand Prescriptions 3.00 1$ Prescription Reduce over-utilization Remove Add Chiropractic, Optical Services and 2.00 Reduce over-utilization Remove Supplies $ Visit Add Optometrist, Non-Emergency and 3.00 '$ Reduce over-utilization Remove Emergency Department Visits Visit Tho state pomrits providera to ,oqui,o individwtls to pay cost sharing a, a condition fo, n,coiving items o, sond,os, subject to G the conditions specified at 42 CFR 447.52(e)(l). This is only permitted for non-exempt individuals with family income above No 100% FPL. Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals If the state targets cost sharing for non-preferred drugs to specific groups of individuals ( entered above), answer the following question: The state charges cost sharing for non-preferred drugs to otherwise exempt individuals. 6 Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department Charged to Otherwise Exempt Individuals If the state charges cost sharing for non-emergency services provided in the hospital emergency department to specific individuals ( entered above), answer the following question: The state charges cost sharing for non-emergency services provided in the hospital emergency department to otherwise 6 exempt individuals. Add Population I Transmittal Number. NC 21-0022 I Remove Population Pa2:e 1 of2 Approval Date: December 28, 202'1 Effective Date: July 1, 2021

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Medicaid Premiums and Cost Sharing State Name:INorth Carolina Transmittal Number: NC - 21 - 0022 0MB Control Number: 0938-1148 Cost Sharing Limitations 42 CFR 447.56 1916 1916A ~The state administers cost sharing in accordance with the limitations described at 42 CFR 447.56, and I 916(a)(2) and G) and 19 I 6A(b) of the Social Security Act, as follows: l<:xemntions Groups of Individuals - Mandatory Exemptions The state may not impose cost sharing upon the following groups of individuals: [!: Individuals ages 1 and older, and under age 18 eligible under the Infants and Children under Age 18 eligibility group ( 42 CFR435.118). [!: Infants under age 1 eligible under the Infants and Children under Age 18 eligibility group (42 CFR 435.118), whose income does not exceed the higher of: [!: 133% FPL; and [!: If applicable, the percent FPL described in section l 902(1)(2)(A)(iv) of the Act, up to 185 percent. [!: Disabled or blind individuals under age 18 eligible for the following eligibility groups: [!: SSI Beneficiaries (42 CFR 435.120). [!: Blind and Disabled Individuals in 209(b) States (42 CFR435.121). [!: Individuals Receiving Mandatory State Supplements ( 42 CPR 435.130). [!: Children for whom child welfare services are made available under Part B of title IV of the Act on the basis of being a child in foster care and individuals receiving benefits under Part E of that title, without regard to age. [!: Disabled children eligible for Medicaid under the Family Opportunity Act (1902(a)(lO)(A)(ii)(XIX) and 1902(cc) of the Act). [!: Pregnant women, during pregnancy and through the postpartum period which begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of pregnancy ends, except for cost sharing for services specified in the state plan as not pregnancy-related. [!: Any individual whose medical assistance for services furnished in an institution is reduced by amounts reflecting available income other than required for personal needs. [! An individual receiving hospice care, as defined in section 1905( o) of the Act. [! Indians who are currently receiving or have ever received an item or service furnished by an Indian health care provider or through referral under contract health services. [! Individuals who are receiving Medicaid because of the state's election to extend coverage to the Certain Individuals Needing Treatment for Breast or Cervical Cancer eligibility group (42 CFR 435.213). Transmittal Number: NC 21-0022 Pa2:e I of 5 Approval Date: December 28, 202'1 Effective Date: July 1, 2021

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Medicaid Premiums and Cost Sharing Groups of Individuals - Optional Exemptions The state may elect to exempt the following groups of individuals from cost sharing: The state elects to exempt individuals under age 19, 20 or 21, or any reasonable category of individuals 18 years of age ~ or over. ~ Indicate below the age of the exemption: (' Under age 19 (' Under age 20 (e Under age 21 (' Other reasonable category The state elects to exempt individuals whose medical assistance for services furnished in a home and community-based ~ setting is reduced by amounts reflecting available income other than required for personal needs. ~ Services - Mandatory Exemptions The state may not impose cost sharing for the following services: [!: Emergency services as defined at section 1932(b)(2) of the Act and 42 CFR 438.l 14(a). [!: Family planning services and supplies described in section 1905(a)(4)(C) of the Act, including contraceptives and pharmaceuticals for which the state claims or could claim federal match at the enhanced rate under section 1903(a)(5) of the Act for family planning services and supplies. [! Preventive services, at a minimum the services specified at 42 CFR 457.520, provided to children under 18 years of age regardless of family income, which reflect the well-baby and well child care and immunizations in the Bright Futures guidelines issued by the American Academy of Pediatrics. [! Pregnancy-related services, including those defined at 42 CFR 440.210(a)(2) and 440.250(p), and counseling and drugs for cessation of tobacco use. All services provided to pregnant women will be considered pregnancy-related, except those services specificially identified in the state plan as not being related to pregnancy. [! Provider-preventable services as defined in 42 CFR 447.26(b). Enforceability of Exemptions The procedures for implementing and enforcing the exemptions from cost sharing contained in 42 CFR 447.56 are (check all that apply): [! To identify that American Indians/Alaskan Natives (AI/AN) are currently receiving or have ever received an item or service furnished by an Indian health care provider or through referral under contract health services in accordance with 42 CFR 447.56(a)(l)(x), the state uses the following procedures: 1ZJ The state accepts self-attestation C The state runs periodic claims reviews [g] The state obtains an Active or Previous User Letter or other Indian Health Services (IRS) document C The Eligibility and Enrollment and MMIS systems flag exempt recipients Transmittal Number: NC 21-0022 Pa2:e 2 of5 Approval Date: December 28, 202'1 Effective Date: July 1, 2021

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Medicaid Premiums and Cost Sharing ~Medicaid premiums and cost sharing incurred by all individuals in the Medicaid household do not exceed an aggregate limit of 5 percent of the family's income applied on a quarterly or monthly basis. [! The percentage of family income used for the aggregate limit is: r. 5% (' 4% (' 3% (' 2% (' 1% (' Other: □% [! The state calculates family income for the purpose of the aggregate limit on the following basis: (' Quarterly (e' Monthly The state has a process to track each family's incurred premiums and cost sharing through a mechanism that does not rely on beneficiary documentation. [! Describe the mechanism by which the state tracks each family's incurred premiums and cost sharing ( check all that apply): ~ As claims are submitted for dates of services within the family's current monthly or quarterly cap period, the state applies the incurred cost sharing for that service to the family's aggregate limit. Once the family reaches the aggregate limit, based on incurred cost sharing and any applicable premiums, the state notifies the family and providers that the family has reached their aggregate limit for the current monthly or quarterly cap period, and are no longer subject to premiums or cost sharing. ~ Managed care organization(s) track each family's incurred cost sharing, as follows: Health plans provide a monthly cost sharing report to the state. The state reconciles quarterly reports with state carved out services. C Other process: [! Describe how the state informs beneficiaries and providers of the beneficiaries' aggregate family limit and notifies beneficiaries and providers when a beneficiary has incurred premiums and cost sharing up to the aggregate family limit and individual family members are no longer subject to premiums or cost sharing for the remainder of the family's current monthly or quarterly cap period: As soon as the beneficiary meets the cost sharing limit, the MMIS records the status and providers receive that information through the MMIS and health plan billing system. Letters are also sent to beneficiaries and providers. The state has a documented appeals process for families that believe they have incurred premiums or cost sharing over ~ the aggregate limit for the current monthly or quarterly cap period. ~ Transmittal Number: NC 21-0022 Pa2:e 4 of5 Approval Date: December 28, 202'1 Effective Date: July 1, 2021

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Non-MAGI Methodologies MEDICAID I Medicaid State Plan I Eligibility I NC2021MS0002O I NC-21-0025 Package Header Package ID NC2021 MS0002O Submission Type Official Approval Date 3/24/2022 Superseded SPA ID New User-Entered D. Family Size SPA ID NC-21-0025 Initial Submission Date 12/28/2021 Effective Date 10/1/2021 1. The family size of an individual for whom the 551 income and resource methodologies are used (as described in section A) includes the persons identified below: a. The individual applying, or b. If the individual lives together with his or her spouse, the individual applying and the spouse, or c. If the individual lives together with his or her parent(s) and the individual is under 21 or has blindness or a disability, the individual applying and the parent(s). 2. The family size of an individual for whom the AFDC income and resource methodologies are used (as described in section A.), includes the persons who would have been included in the family under the state's July 16, 1996 AFDC state plan, except where the state has elected to use the MAGI-like methodologies (as described in section E). 3. The state defines family size for one or more of the following FPL eligibility groups to include others beyond those identified in D.1. and D.2. 0 Yes 0 No a. Qualified Medicare Beneficiaries (described in section 1902(a)(10)(E)(i) of the Act) n b. Specified Low Income Medicare Beneficiaries (described in section 1902(a)(10)(E)(iii) of the Act) c. Qualifying Individuals (described in section 1902(a)(1 0)(E)(iv) of the Act) n d. Qualified Disabled and Working Individuals (described in section 1902(a)(1 0)(E)(ii) of the Act) e. Age and Disability-Related Poverty Level (described in section 1902(aX10)(A)(ii)(X) of the Act) f. Work Incentives (described in section 1902(a)(1 0)(A)(ii)()(III) of the Act) g. Family Opportunity Act Children with a Disability (described in section 1902(a)(1 0)(A)(ii)(XIXJ of the Act) h. Individuals Receiving State Plan Home and Community-Based Services (described in 42 CFR 435.219) 4. The state uses the same definition of family size for the selected FPL eligibility groups. 0 Yes 0 No 5. For the selected FPL eligibility groups, family size is defined as follows: O a. Family is defined as the individual, the individual's spouse and the individual's children under age 18 living together in the same household. If the individual is a child, the child's parents and siblings under age 18 are also included in the household if living together. Optional description: O b. The state uses another definition of family.

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OFFICIAL Medicaid Premiums and Cost Sharing State Name:INorth Carolina Transmittal Number: NC -22 - 0020 0MB Control Number: 09381148 Cost Sharing Requirements 1916 1916A 42 CFR 447.50 through 447.57 (excluding 447.55) The state charges cost sharing (deductibles, co-insurance or co-payments) to individuals covered under Medicaid. IZJ The state assures that it administers cost sharing in accordance with sections 1916 and 1916A of the Social Security Act and 42 CFR 447.50 through 447.57. General Pro,•isions 1ZJ The cost sharing amounts established by the state for services are always less than the amount the agency pays for the service. ljJ No provider may deny services to an eligible individual on account of the individual's inability to pay cost sharing, except as elected by the state in accordance with 42 CFR 447.52(e)( I). ljJ The process used by the state to infonn providers whether cost sharing for a specific item or service may be in1posed on a beneficiary and whether the provider may require the beneficiary to pay the cost sharing charge, as a condition for receiving the item or service, is (check all that apply): ~ The state includes an indicator in the Medicaid Management Infom1ation System (MMIS) D The state includes an indicator in the Eligibility and Enrollment System D Toe state includes an indicator in the Eligibility Verification System D Toe state includes an indicator on the Medicaid card, which the beneficiary presents to the provider ~ Other process Description: The state provides billing guidance to providers and MCOs that is incorporated by reference. ~ Contracts with managed care organizations (MCOs) provide that any cost-sharing charges the MCO imposes on Medicaid enrollees are in accordance with the cost sharing specified in the state plan and the requirements set forth in 42 CFR 447.50 through 447 .57. Cost Sharing for Non-Emergency Services Provided in a HosJlital Emergency DeJlartment The state imposes cost sharing for non-emergency services provided in a hospital emergency department. IZI The state ensures that before providing non-emergency services and imposing cost sharing for such services, that the hospitals providing care: TN 22-0020 Supersedes NC 21-0022 Approval Date: 12/02/2022 Pagel of3 Effective Date: 07/01/2022

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OFFICIAL Medicaid Premiums and Cost Sharing ~ Conduct an appropriate medical screening under 42 CFR 489 .24, subpart G to detennine that the individual does not need emergency services; ~ Infonn the individual of the amount of his or her cost sharing obligation for non-emergency services provided in the emergency department; ~ Provide the individual with the name and location of an available and accessible alternative non-emergency services provider; ~ Detennine that the alternative provider can provide services to the individual in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing if the individual is otherwise exempt from cost sharing; and ~ Provide a referral to coordinate scheduling for treatment by the alternative provider. 1ZJ The state assures that it has a process in place to identify hospital emergency department services as non-emergency for purposes of imposing cost sharing. This process does not limit a hospital's obligations for screening and stabilizing treatment of an emergency medical condition under section 1867 of the Act; or modify any obligations under either state or federal standards relating to the application of a prudent-layperson standard for payment or coverage of emergency medical services by any managed care organization. The process for identifying emergency department services as non-emergency for purposes of imposing cost sharing is: The state maintains a list of codes that will be periodically updated. Cost Sharing for Drugs The state charges cost sharing for dmgs. The state has established differential cost sharing for preferred and non-preferred drugs. ~ All drugs will be considered preferred dmgs. Beneficiary and Public Notice Requirements IZJ Consistent with 42 CFR 447 .57, the state makes available a public schedule describing current cost sharing requirements in a manner that ensures that affected applicants, beneficiaries and providers are likely to have access to the notice. Prior to submitting a SPA which establishes or substantially modifie.s existing cost sharing amounts or policies, the state provides the public with advance notice of the SPA, specifying the amount of cost sharing and who is subject to the charges, and provides reasonable opportunity for stakeholder comment. Documentation demonstrating that the notice requirements have been met are submitted with the SPA. The state also provides opportunity for additional public notice if cost sharing is substantially modified during the SPA approval process. Other Relevant Information The State has copayments for covered Outpatient Phannacy medications for adults (21 and older) in the traditional Medicaid program. Those copayments are $4 per prescription. Groups of Individuals who are mandatorily exempt from cost sharing as described in section G3 have $0 co-payment for all prescriptions. TN 22-0020 Supersedes NC 21-0022 Approval Date: 12/02/2022 Page 2 of3 Effective Date: 07/01/2022

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OFFICIAL Medicaid Premiums and Cost Sharing State Name:INorth Carolina Transmittal Number: NC -22 - 0020 0MB Control Number: 09381148 Cost Sharing Amounts - Targeting G2c 1916 1916A 42 CFR 447.52 through 54 The state targets cost sharing to a specific group or groups of individuals. ~ Population Name (optional): I I Eligibility Group(s) Included: IAII Eligibility Groups With Exception ofBCCM Beneficiaries I Incomes Greater than I ol TO Incomes Less than or Equal to I 250% FPLI Dollars or Add Service Amount Percentage Unit Explanation Remove Add Physician (Not to include inpatient 4.00 D I Visit Reduce over-utilization Remove services) Add Generic and Brand Prescriptions 4.00 1$ I Prescription Reduce over-utilization Remove Add Chiropractic Services and Supplies 4.00 1$ !visit Reduce over-utilization Remove Add Optometrist and Optical Services 4.00 1$ !visit Reduce over-utilization Remove Add Dental Services 4.00 1$ !visit Reduce over-utilization Remove Add Outpatient 4.00 1$ I visit Reduce over-utilization Remove Add Podiatrist 4.00 1$ !visit Reduce over-utilization Remove Add Non-Emergency Emergency 4.00 D !visit Reduce over-utilization Remove Department Visits The state penni~ providers 1-0 require individuals to pay cost sharing as a condition for receivll1g iren~ or services, subject to G the conditions specified at 42 CFR 447.52(e)(l). This is only pennined for non-exempt individuals with family income above No 100%FPL. Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt lndiYiduals If the state targets cost sharing for non-preferred drugs to specific groups of individuals (entered above), answer the following question: The state charges cost sharing for non-preferred drugs to otherwise exempt individuals. G Cost Sharing for Non-emergency SerYices ProYided in the Hos1>ital Emergency Department Charged to Otherwise Exemnt lncliYiduals If the state charges cost sharing for non-emergency services provided in the hospital emergency department to specific individuals (entered above), answer the following question: TN 22-0020 Supersedes NC 21-0022 Approval Date: 12/02/2022 Page l of2 Effective Date: 07/01/2022

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OFFICIAL Medicaid Premiums and Cost Sharing State Name:INorth Carolina Transmittal Number: NC - 22 - 0020 0MB Control Number: 0938 1148 Cost Sharing Limitations 42 CFR 447.56 1916 1916A lZJ Tue state administers cost sharing in accordance with the limitations described at 42 CFR 447 .56, and l 9 l 6(a)(2) and (j) and 19 l 6A(b) of the Social Security Act, as follows: Exemntinns GrouJlS of Individuals - Mandatory Exemptions The state may not impose cost sharing upon the following groups of individuals: ~ Individuals ages I and older, and under age 18 eligible under the Infants and Children under Age 18 eligibility group (42 CFR 435.118). ~ Infants under age I eligible under the Infants and Children under Age I 8 eligibility group ( 42 CFR 435.118), whose income does not exceed the higher of: ~ 133% FPL; and ~ If applicable, the percent FPL described in section 1902(1)(2)(A)(iv) of the Act, up to 185 percent. ~ Disabled or blind individuals under age 18 eligible for the following eligibility groups: ~ SSI Beneficiaries (42 CFR 435.120). ~ Blind and Disabled Individuals in 209(b) States (42 CFR 435.121). ~ Individuals Receiving Mandatory State Supplements (42 CFR 435. 130). ~ Children for whom child welfare services are made available under Part B of title IV of the Act on the basis of being a child in foster care and individuals receiving benefits under Part E of that title, without regard to age. ~ Disabled children eligible for Medicaid llllder the Family Opportunity Act (1902(a)(l 0)(A)(ii)(XIX) and 1902(cc) of tl1e Act). ~ Pregnant women, during pregnancy and through the postpartum period which begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of pregnancy ends, except for cost sharing for services specified in the state plan as not pregnancy-related. ~ Any individual whose medical assistance for services filrnishe<l in an instinttion is reduced by ainowlts reflecting available income other than required for personal needs. ~ An individual receiving hospice care, as defined in section 1905(0) of the Act. ~ Indians who are currently receiving or have ever received an item or service furnished by an Indian health care provider or through referral under contract health services. ~ Individuals who are receiving Medicaid because of the state's election to extend coverage to the Certain Individuals Needing Treatment for Breast or Cervical Cancer eligibility group (42 CFR 435.213). Groups of In<livicluals - O()tional Exemptions TN 22-0020 Supersedes NC 21-0022 11pprova1 ua1e: ""'' Effective Date: 07/01/2022

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OFFICIAL Medicaid Premiums and Cost Sharing The state may elect to exempt the following groups of individuals from cost sharing: The state elects to exempt individuals under age 19, 20 or 21, or any reasonable category of individuals 18 years of age ~ or over. ~ Indicate below the age of the exemption: C Under age 19 C Under age 20 (e Under age 21 C Other reasonable category The state elects to exempt individuals whose medical assistance for services furnished in a home and community-based ly::7 setting is reduced by amounts reflecting available income other than required for personal needs. ~ Services - Mandatory Exem1ltions The state may not impose cost sharing for the following services: ~ Emergency services as defined at section 1932(b)(2) of the Act and 42 CFR 438. l l4(a). ~ Family planning services and supplies described in section 1905(a)(4)(C) of the Act, including contraceptives and phannaceuticals for which the state claims or could claim federal match at the enhanced rate under section 1903(a)(5) of the Act for family planning services and supplies. ~ Preventive services, at a minimum the services specified at 42 CFR 457.520, provided to children under l 8 years of age regardless of family income, which reflect the well-baby and well child care and immunizations in the Bright Futures guidelines issued by the American Academy of Pediatrics. ~ Pregnancy-related services, including those defined at 42 CFR 440.21 0(a)(2) and 440.250(p ), and counseling and drngs for cessation of tobacco use. All services provided to pregnant women will be considered pregnancy-related, except those services specificially identified in the state plan as not being related to pregnancy. ~ Provider-preventable services as defined in 42 CFR 447.26(b). Enforceability of Exem1>tions The procedures for implementing and enforcing the exemptions from cost sharing contained in 42 CFR 447.56 are (check all that apply): ~ To identify that American Indians/ Alaskan Natives (Al/ AN) are currently receiving or have ever received an item or service furnished by an Indian health care provider or th.rough referral under contract health services in accordance with 42 CFR 447.56(a)(l)(x), the state uses the following procedures: [gl Tue state accepts self~attestation D The state runs periodic claims reviews [gl The state obtains an Active or Previous User Letter or other Indian Health Services (IHS) document D The Eligibility and Enrollment and MMlS systems flag exempt recipients [gl Other procedure TN 22-0020 Supersedes NC 21-0022 Approval Date: 12/02/2022 Page 2 of5 Effective Date: 07/01/2022

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OFFICIAL Medicaid Premiums and Cost Sharing Description: Require proof of tribal enrollment for federally recognized tribal members. Additional description of procedures used is provided below (optional): ~ To identify all other individuals exempt from cost sharing, the state uses the following procedures (check all that apply): igj The MMIS system flags recipients who are exempt D Tl1e Eligibility and Enrollment System flags recipients who are exempt D Tl1e Medicaid card indicates if beneficiary is exempt D Tl1e Eligibility Verification System notifies providers when a beneficiary is exempt ~ Other procedure Description: Services fumished by PHPs and LME/MCOs for behavioral health, I/DD and TBI are not subject to copayments. All services ftm1ished by a Rural Health Clinic as defined by 42 U.S.C. 1396d(l)( 1) or a Federally Qualified Health Clinic as defined by 42 U.S.C. 1396d(l)(2) are not subject to co-payments. Additional description of procedures used is provided below (optional): P,lvment~ to Provirler~ lZJ The state reduces the payment it makes to a provider by the amount of a beneficiary's cost sharing obligation, regardless of whether the provider has collected the payment or waived the cost sharing,~ as provided under 42 CFR 447.56(c). The state contracts with one or more managed care organizations to deliver services under Medicaid. lZI The state calculates its payments to managed care organizations to include cost sharing established under the state plan for beneficiaries not exempt from cost sharing, regardless of whether the organization imposes the cost sharing on its recipient members or the cost sharing is collected. A.oorMJate Limits lZJ Medicaid premiums and cost sharing incurred by all individuals in the Medicaid household do not exceed an aggregate limit of 5 percent of the family's income applied on a quarterly or monthly basis. TN 22-0020 Supersedes NC 21-0022 Approval Date: 12/02/2022 Page 3 of5 Effective Date: 07/01/2022

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OFFICIAL Medicaid Premiums and Cost Sharing ~ The percentage of family income used for the aggregate limit is: Ce' 5% (' 4% (' 2% (' 1% (' Other: D¾ ~ Toe state calculates family income for the purpose of the aggregate limit on the following basis: (' Quarterly Ce Monthly The state has a process to track each family's incurred premiums and cost sharing through a mechanism that does not rely on beneficiary documentation. ~ Describe the mechanism by which the state tracks each family's incurred premiums and cost sharing (check all that apply): [gl As claims are submitted for dates of seivices within the family's current monthly or quarterly cap period, the state applies the incurred cost sharing for that seivice to the family's aggregate limit. Once the family reaches the aggregate limit, based on incurred cost sharing and any applicable premiums, the state notifies the family and providers that the family has reached their aggregate limit for the current monthly or quarterly cap period, and are no longer subject to premiums or cost sharing. [gl Managed care organization(s) track each family's incurred cost sharing, as follows: Health plans provide a monthly cost sharing report to the state. D Other process: ~ Describe how the state infonns beneficiaries and providers of the beneficiaries' aggregate family limit and notifies beneficiaries and providers when a beneficiary has incurred premiums and cost sharing up to the aggregate family limit and individual family members are no longer subject to premiums or cost sharing for the remainder of the family's current monthly or quarterly cap period: As soon as the beneficiary meets the cost sharing limit, the MMIS records the status and providers receive that infom1ation through the MMIS and health plan billing system. Letters are also sent to beneficiaries and providers. The state has a documented appeals process for families that believe they have incurred premiums or cost sharing over ~ the aggregate limit for the current monthly or quarterly cap period. ~ ~ Describe the process used to reimburse beneficiaries and/or providers if the family is identified as paying over the aggregate limit for the month/quarter: !Beneficiaries can contact beneficiary services and is reviewed on a case by case basis. TN 22-0020 Supersedes NC 21-0022 Approval Date: 12/02/2022 Page4 of5 Effective Date: 07/01/2022

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DocuSign Envelope ID: E096FC61-216F-4C7E-BD67-675FBECCAC67 DEPARTMENT OF HEALTH ANDHUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANSMITTAL NUMBER 2 3 0 0 2 8 2. STATE NC 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT XIX XXI TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE October 01, 2023 5. FEDERAL STATUTE/REGULATION CITATION 42 C.F.R. §435.119 / NC SL-2023-07 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a. FFY 24 $ 0 b. FFY 25 $ 0 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Supplement 18 to Attachment 2.6A, Pages 1- 6(new) 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) N/A 9. SUBJECT OF AMENDMENT Medicaid Expansion FMAP 10. GOVERNOR’S REVIEW (Check One) GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Secretary 11. SIGNATURE OF STATE AGENCY OFFICIAL 15. RETURN TO Office of the Deputy Secretary Department of Health and Human Services 2001 Mail Service Center Raleigh, NC 27699-20014 12. TYPED NAME Jay Ludlam 13. TITLE Deputy Secretary 14. DATE SUBMITTED 8/15/2023 FOR CMS USE ONLY 16. DATE RECEIVED 17. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 19. SIGNATURE OF APPROVING OFFICIAL 20. TYPED NAME OF APPROVING OFFICIAL 21. TITLE OF APPROVING OFFICIAL 22. REMARKS FORM CMS-179 (09/24) Instructions on Back August 15, 2023 October 12, 2023 October 12, 2023 Charlie Arnold Director of Financial Policy Pen/Ink Authorizations: Block 4: REMOVE - October 1, 2023; ADD: December 1, 2023 Block 5 - REMOVE - NC SL-2023-07; ADD: 42 CFR Part 440, Subpart C Block 7: ADD: Attachment A and Attachment E Charlie L. Arnold -S Digitally signed by Charlie L. Arnold -S Date: 2023.10.12 06:03:24 -04'00'

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Attachment E Transition Populations. The North Carolina Department of Health and Human Services (DHHS) is committed to providing a smooth transition for those currently enrolled in Medicaid who may be eligible under the new adult group. DHHS intends to align its adult group Alternative Benefit Plan package with the State Plan benefit package. The transition populations include: • Family Planning Benefit Program (FPBP). FPBP is North Carolina’s limited-benefit family planning program authorized through a State Plan Amendment. The program covers non- pregnant individuals (of any age) with MAGI-based household income at or below 195 percent of the federal poverty level (FPL). Prior to Medicaid expansion effective date, DHHS anticipates that during the unwinding period, most people who are no longer eligible for full Medicaid benefits due to income will be moved to FPBP, if eligible. Upon Medicaid expansion, most current FPBP enrollees with incomes below 133 percent of the FPL will be eligible for full Medicaid in the adult group and will be moved to that group. • Additional MAGI Medicaid Populations with Income Below 133 Percent of the FPL. As a condition of receiving the 6.2 percent enhanced FMAP, North Carolina has continuously maintained coverage for Medicaid enrollees (“continuous enrollment period”). As part of the State’s Medicaid expansion transition plan, the State will also evaluate whether individuals in other Medicaid eligibility categories can be transitioned to the new adult group when they are reviewed as part of their renewal process, as explained further below. These potential transition populations will include: o Children who have turned 19 (or 21 in the optional Reasonable Classification group) and whose coverage was maintained during the continuous enrollment period; o Individuals at the end of their 12-month postpartum period; o Parents/Caretaker Relatives whose coverage was maintained during the continuous enrollment period but are no longer eligible; and o Individuals whose most recent enrollment has been in a medically needy group. Transition Process. • Individuals whom the State has eligibility information that is less than 12 months old. The State’s eligibility and enrollment system contains MAGI-based household income data for each enrollee from their most recent eligibility determination. The State will use the most recent eligibility determination information if it is less than 12 months old to transfer individuals identified as eligible for expanded Medicaid to a new adult group aid category with coverage beginning on the effective date of expansion. These individuals will retain their current redetermination date and will undergo a full redetermination process during their redetermination period. At least 10 days prior to an individual’s effective date of coverage in the new adult expansion group, the State will send a notice which complies 42 CFR Part 431, Subpart E and informs the individual of their coverage effective date, change in benefits, reporting obligations and where to go to have questions answered. • Individuals whom the State has eligibility information that is greater than 12 months old. The State will conduct a full redetermination at the regularly scheduled renewal date for individuals for whom the State has eligibility information that is older than 12 months old. If the State finds they are eligible under the new adult group through an ex-parte redetermination process or

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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 November 14, 2023

Jay Ludlam Deputy Secretary of Medical Assistance Division of Medical Assistance 2001 Mail Service Center 1985 Umstead Drive Raleigh, NC 27699-20014

Re: North Carolina State Plan Amendment (SPA) 23-0029 Companion Letter

Dear Deputy Secretary Ludlam:

This letter is being sent as a companion to the Centers for Medicare & Medicaid (CMS) approval of North Carolina State Plan Amendment (SPA) Transmittal Number 23-0029, which effectuates Essential Health Benefits (EHBs) in Alternative Benefit Plan (ABP) coverage for the adult group population. The amendment was submitted on August 16, 2023, with an effective date of December 1, 2023.

CMS is providing this letter to document the relevance and application of North Carolina’s ongoing Mental Health Parity and Addiction Equity Act (parity) analysis to the ABP. Section 1937(b)(6) of the Social Security Act applies parity requirements to ABPs delivered through fee-for-service (FFS) and managed care delivery systems. North Carolina intends to provide ABP benefits, which are aligned with the State’s approved Medicaid state plan, through both FFS and existing managed care delivery systems. During the review of NC SPA 23-0029 it was noted that North Carolina and CMS previously established a plan to document parity compliance for beneficiaries receiving services through the managed care organizations (MCOs) and to modify current operations as needed to comply with parity.1

As such, the ABP service package and delivery systems must be included as a part of the ongoing parity analysis and compliance documentation process. An outstanding milestone in that effort is conducting a parity analysis of treatment limitations in the state’s clinical coverage policies (CCPs), which apply to enrollees in all delivery systems.

The State will propose a timeline to complete the parity compliance analysis no later than November 17, 2023. CMS will assess the State’s proposal and provide feedback. Upon completion of the analysis, if there are mental health and/or substance use disorder treatment limitations—in

_______________________________________________________________________________________ 1 North Carolina Medicaid Mental Health Parity Analysis – Standard Plan and Tailored Plan. March 20, 2023. CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

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Page 1 of 1 Alternative Benefit Plan State Name: North Carolina Attachment 3.1-L- OMB Control Number: 09381148 Transmittal Number: NC - 23 - 0029 Voluntary Benefit Package Selection Assurances - Eligibility Group under Section 1902(a)(10)(A)(i)(VIII) of the Act ABP2a The state/territory has fully aligned its benefits in the Alternative Benefit Plan using Essential Health Benefits and subject to 1937 requirements with its Alternative Benefit Plan that is the state’s approved Medicaid state plan that is not subject to 1937 requirements. Therefore the state/territory is deemed to have met the requirements for voluntary choice of benefit package for individuals exempt from mandatory participation in a section 1937 Alternative Benefit Plan. Yes Explain how the state has fully aligned its benefits in the Alternative Benefit Plan using Essential Health Benefits and subject to 1937 requirements with its Alternative Benefit Plan that is the state’s approved Medicaid state plan that is not subject to 1937 requirements. North Carolina has fully aligned its ABP to its Standard State Plan and will offer the new adult group all the same amount, scope, and duration of benefits offered to its non-expansion populations under its State Plan. 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 5 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.20160722 OFFICIAL TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 D D

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OFFICIAL Alternative Benefit Plan State Name:INorth Carolina Transmittal Number: NC. 23 0029 Attachment 3.1-L-D 0MB Control Number: 0938-1148 Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package Select one of the following: (' The state/territory is amending one existing benefit package for the population defined in Section 1. Ci The state/territory is creating a single new benefit package for the population defined in Section I. Name of benefit package: INorth Carolina Adult Group ABP Selection of ERB-Benchmark Plan The state/territory must select an ERB-benchmark plan as the basis for providing Essential Health Benefits in its Benchmark or Benchmark-Equivalent Package. ERB-benchmark plan name: !North Carolina Blue Cross and Blue Shield "Blue oral The ERB-benchmark plan is the same as the Section 1937 Coverage option: ~ Indicate the ERB-benchmark option as described at 45 CFR 156. 11 l(b)(2)(B) the state/territory will use as its ERB- benchmark plan: ABP3.1 State/Territory is selecting one of the below options to design an ERB package that complies with the requirements for the individual insurance market under 45 CFR 156.100 through 156.125. Ci State/Territory is selecting the ERB-benchmark plan used by the state/territory for the 2017 plan year. (' State/Territory is selecting one of the ERB-benchmark plans used for the 2017 plan year by another state/territory. State/ Territory selects the following ERB-benchmark plan used for the 2017 plan year but will (' replace coverage of one or more of the categories of ERB with coverage of the same category from the 2017 ERB-benchmark plan of one or more other states (' Select a set of benefits consistent with the 10 ERB categories to become the new ERB-benchmark plan. (Complete and submit the ABP5: Benefits Description form to describe the set of benefits.) Type of ERB-benchmark plan: Ci Largest plan by enrollment of the three largest small group insurance products in the state's small group market. (' Any of the largest three state employee health benefit plans by enrollment. (' Any of the largest three national FERBP plan options open to Federal employees in all geographies by enrollment. (' Largest insured commercial non-Medicaid HMO. TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2Pigl 1 of3

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OFFICIAL Alternative Benefit Plan Assurances The state/territory assures the EHB plan meets the scope of benefits standards at 45 CFR 156. l l I(b), does not exceed IZ] generosity of most generous among a set of comparison plans, provides appropriate balance of coverage among l 0 ✓ EHB categories, and the scope of benefits is equal to, or greater than, the scope of benefits provided under a typical employer plan as defined at 45 CFR 156. l l I(b)(2). IZ] The state/territory assures that all services in the ERB-benchmark plan have been accounted for throughout the benefit ✓ chart found in ABP 5. r7I The state/territory assures the accuracy of all information in ABP5 depicting amount, duration and scope parameters of tLJ services authorized in the currently approved Medicaid State Plan. Selection of the Section 1937 Coverage Option The state/territory selects as its Section 1937 Coverage option the following type of Benchmark Benefit Package or Benchmark- Equivalent Benefit Package under this Alternative Benefit Plan ( check one): (i' Benchmark Benefit Package. (' Benchmark-Equivalent Benefit Package. The state/territory will provide the following Benchmark Benefit Package (check one that applies): \ The Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employee Health Benefit Program (FEHBP). (' State employee coverage that is offered and generally available to state employees (State Employee Coverage): r A commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state/territory (Commercial HMO): (i' Secretary-Approved Coverage. (i' The state/territory offers benefits based on the approved state plan. r The state/territory offers an array of benefits from the section 1937 coverage option and/or base benchmark plan benefit packages, or the approved state plan, or from a combination of these benefit packages. (i' The state/territory offers the benefits provided in the approved state plan. (' Benefits include all those provided in the approved state plan plus additional benefits. (' Benefits are the same as provided in the approved state plan but in a different amount, duration and/or scope. r The state/territory offers only a partial list of benefits provided in the approved state plan. (' The state/territory offers a partial list of benefits provided in the approved state plan plus additional benefits. Please briefly identify the benefits, the source of benefits and any limitations: The State is aligning its ABP Plan with Medicaid State Plan benefits Other Information Related to Selection of the Section 1937 Coverage Option and the EHB-Benchmark Plan (optional): TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2Pigl 2 of3

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OFFICIAL Alternative Benefit Plan Ii] 5. Essential Health Benefit: Mental health and substance use disorder services including Collapse All 0 behavioral health treatment The state/tel1'itory assures that it does not apply any financial requirement or treatment limitation to mental health or 0 substance use disorder benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation of that type applied to substantially all medical/surgical benefits in the same classification. Benefit Provided: Source: I Remove I !Inpatient Psychiatric Hosptialization I !state Plan 1905(a) I Authorization: Provider Qualifications: !Prior Authorization I !Medicaid State Plan I Amount Limit: Duration Limit: lnone I lnone I Scope Limit: !see below I Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: See Attaclunent 3 .1-A, 16, Inpatient psychiatric facility services for individuals under 21 years of age These services are provided before the recipient reaches age 21 or, if the recipient was receiving the services innnediately before he or she reached age 21, before the earlier of the following: (a) The date he or she no longer requires the services; or (b) The date he or she reaches age 22. Benefit Provided: Source: I Remove I I Outpatient Behavioral Health Services I I state Plan 1905(a) I Authorization: Provider Qualifications: !Yes I !Medicaid State Plan I Amount Limit: Duration Limit: !None I INone I Scope Limit: !see below I Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: See Attaclunent 3 .1-A.1, 13 .d. Rehabilitative services (Other diagnostic, screening, preventive, treatment, and rehabilitative services, i.e., other than those provided elsewhere in the plan) Outpatient behavioral health and substance use disorder services provided are: • Psychotherapy services • Diagnostic assessment • Qualified Professional • Psychosocial rehabilitation • Pa1tial hospitalization - . - -- - - --·- I ,-.. 1-.v .oL~• --.c.._,. - ·rr - •-• ----• ■ ■ ~· .. , _ __ ..... 'I,,.' ---- · ·-· - ---- Supersedes: NEW Page 11 of 43

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Page 12 of 43 Alternative Benefit Plan • Mobile crisis management • Community Support Team (adults) • Assertive Community Treatment • Opioid Treatment • Substance Abuse Intensive Outpatient (SAIOP) • Substance Abuse Comprehensive Outpatient Treatment (SACOT) • Ambulatory Detoxification • Non-Hospital Medical Detoxification For psychotherapy services (i.e., basic benefits, outpatient): For individuals 21 years and older, the first 8 visits do not require prior approval. Medicaid eligible adults (21 years and older) may be self-referred For mobile crisis management: Prior authorization is required after the first 8 hours. A mental health and substance use disorder parity analysis will be performed for all ABP services and delivery systems to assure compliance with each of the requirements of parity. Benefit Provided: Rehab BH Services in Residential Settings Source: State Plan 1905(a) Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: See below Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: See Attachment 3.1-A.1, 13.d. Rehabilitative services (Other diagnostic, screening, preventive, treatment, and rehabilitative services, i.e., other than those provided elsewhere in the plan) Behavioral health and substance use disorder services provided in residential settings are: • Professional Treatment Services in Facility-Based Crisis Programs (FBC) • Substance Abuse Non-Medical Community Residential Treatment • Substance Abuse Medically Monitored Residential Treatment • Medically Monitored or Alcohol Drug Addiction Treatment Center Detoxification (ADATC)/Crisis Stabilization • High-Risk Intervention Services for Children NC has an approved 1115 demonstration that includes a waiver of the institution for mental disease (IMD) exclusion for substance use disorder (SUD) treatment. Benefit Provided: Source: Remove Authorization: Prior Authorization Provider Qualifications: OFFICIAL TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 I 1 1 I I I 1 1 I 1 1 I I 1 1 I I I 1 1

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OFFICIAL Alternative Benefit Plan Ii] 7. Essential Health Benefit: Rehabilitative and habilitative services and devices Collapse All 0 The state/te1ritory assures that it is not imposing limits on habilitative services and devices that are more stringent than [ZI limits on rehabilitative services ( 45 CFR l 56. l l 5(a)(5)(ii)). Fwther, the state/te1ritory understands that separate coverage limits must also be established for rehabilitative and habilitative services and devices. Combined rehabilitative and habilitative limits are allowed, if these limits can be exceeded based on medical necessity. I I Benefit Provided: Source: Remove I Skilled Nursing Facility Services I !state Plan 1905(a) I Authorization: Provider Qualifications: !Prior Authorization I !Medicaid State Plan I Amount Limit: Duration Limit: !None I !None I Scope Limit: !see below I Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: See Attachment 3.1-A, 4.a., Nursing facility services This entty represents sho1t te1m nursing facility care. The same item is captured under "other 1937 covered benefits" for the pwposes of long-term custodial care." Benefit Provided: Source: I Remove I I Chiropractic services I I state Plan 1905(a) I Authorization: Provider Qualifications: IPrior Authorization I !Medicaid State Plan I Amount Limit: Duration Limit: I see below I lsee below I Scope Limit: I see below I Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: SeeAttachment 3.l-A.l, 6.c., Chiropractors' Services Combined optional services are limited to eight per recipient per State fiscal year. This limitation does not apply to EPSDT eligible children. Exceptions to the limit may be authorized by the State when additional visits are medically necessary. Benefit Provided: Source: I Remove I !Home Health Svcs.-Med Supplies, Equip, Appliances I !state Plan 1905(a) I Authorization: Provider Qualifications: !Prior Authorization I !Medicaid State Plan I . . - .... , ..... ·---- --- - .. ---.. , ____ Supersedes: NEW Page 15 of 43

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Page 23 of 43 Alternative Benefit Plan 12. Base Benchmark Benefits Not Covered due to Substitution or Duplication Collapse All Base Benchmark Benefit that was Substituted: Primary Care Visit to Treat an Injury or Illness Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Physicians Services under EHB1: Ambulatory Patient Services. Base Benchmark Benefit that was Substituted: Specialist visit Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Physicians Services under EHB1: Ambulatory Patient Services. Base Benchmark Benefit that was Substituted: Other Practitioner Office Visit Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Other practitioners’ services under EHB1: Ambulatory Patient Services. Base Benchmark Benefit that was Substituted: Outpatient Surgery Physician/Surgical Services Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Outpatient Hospital Services and as Clinic Services under EHB l: Ambulatory Patient Services. Base Benchmark Benefit that was Substituted: Hospice Services Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Outpatient Hospice Services under EHB l: Ambulatory Patient Services. Base Benchmark Benefit that was Substituted: Private-Duty Nursing Source: Base Benchmark Remove OFFICIAL TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 IZl □ I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I

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Page 24 of 43 Alternative Benefit Plan Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Private Duty Nursing Services under EHB l: Ambulatory Patient Services. Base Benchmark Benefit that was Substituted: Urgent Care Centers or Facilities Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Clinic Services under EHB l: Ambulatory Patient Services. Base Benchmark Benefit that was Substituted: Home Health Care Services Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Home Health Services under EHB l: Ambulatory Patient Services. Base Benchmark Benefit that was Substituted: Emergency Room Services Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Outpatient Hospital Services under EHB 1: Ambulatory Patient Services. Base Benchmark Benefit that was Substituted: Emergency Transportation/Ambulance Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Ambulance Services under EHB 2: Emergency Services. Base Benchmark Benefit that was Substituted: Inpatient Hospital Services (e.g., Hospital Stay) Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Inpatient Hospital Services under EHB 3: Hospitalization. OFFICIAL TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I

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Page 25 of 43 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Bariatric Surgery Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Physicians Services under EHB1: Ambulatory Patient Services and Inpatient hospital services under EHB3: Hospitalization. Base Benchmark Benefit that was Substituted: Skilled Nursing Facility Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Skilled Nursing Facility Services under EHB 7: Rehabilitative and habilitative services and devices. Base Benchmark Benefit that was Substituted: Prenatal and Postnatal Care Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Maternity Care – Outpatient Hospital Services and Maternity Care – Physicians’ Services under EHB 4: Maternity and Newborn Care. Base Benchmark Benefit that was Substituted: Delivery and Inpatient Services for Maternity Care Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Maternity Care – Inpatient Hospital Services under EHB 4: Maternity and Newborn Care. Base Benchmark Benefit that was Substituted: Mental/Behavioral Health Outpatient Services Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Outpatient Behavioral Health Services under EHB 5: Mental Health and Substance Use Disorder Services. Base Benchmark Benefit that was Substituted: Mental/Behavioral Health Inpatient Services Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: OFFICIAL TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I

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Page 26 of 43 Alternative Benefit Plan Duplication: Covered under the North Carolina Medicaid State Plan as Inpatient Psychiatric Services under EHB 5: Mental Health and Substance Use Disorder Services. Base Benchmark Benefit that was Substituted: Substance Abuse Disorder Outpatient Services Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Outpatient Behavioral Health Services under EHB 5: Mental Health and Substance Use Disorder Services. Base Benchmark Benefit that was Substituted: Substance Abuse Disorder Inpatient Services Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Inpatient Psychiatric Services and Rehab BH Services in Residential Settings under EHB 5: Mental Health and Substance Use Disorder Services. Base Benchmark Benefit that was Substituted: Generic Drugs Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Pharmacy and Prescription Drugs and Medication Management under EHB 6: Prescription Drugs. Base Benchmark Benefit that was Substituted: Preferred Brand Drugs Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Prescription Drugs and Medication Management under EHB 6: Prescription Drugs. Base Benchmark Benefit that was Substituted: Non-Preferred Brand Drugs Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Pharmacy and Prescription Drugs and Medication Management under EHB 6: Prescription Drugs. OFFICIAL TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I

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Page 27 of 43 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Specialty Drugs Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Pharmacy and Prescription Drugs and Medication Management under EHB 6: Prescription Drugs. Base Benchmark Benefit that was Substituted: Outpatient Rehabilitation Services Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Occupational Therapy and Physical Therapy under EHB 7: Rehabilitative and Habilitative Services. Base Benchmark Benefit that was Substituted: Habilitation Services Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Occupational Therapy and Physical Therapy under EHB 7: Rehabilitative and Habilitative Services. Base Benchmark Benefit that was Substituted: Chiropractic Care Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Chiropractic Services under EHB 7: Rehabilitative and Habilitative Services. Base Benchmark Benefit that was Substituted: Durable Medical Equipment Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Home Health Services – Medical supplies, equipment and appliances under EHB 7: Rehabilitative and Habilitative Services. Base Benchmark Benefit that was Substituted: Hearing Aids Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: OFFICIAL TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I

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Page 28 of 43 Alternative Benefit Plan Duplication: Covered under the North Carolina Medicaid State Plan as Home Health Services – Medical supplies, equipment and appliances under EHB 7: Rehabilitative and Habilitative Services. Base Benchmark Benefit that was Substituted: Imaging (CT/PET Scans, MRIs) Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Laboratory and X-ray services under EHB 8: Laboratory Services. Base Benchmark Benefit that was Substituted: Preventive Care/Screening/Immunization Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Physicians Services under EHB1: Ambulatory Patient Services and as Pharmacy Base Benchmark Benefit that was Substituted: Routine Eye Exam for Children Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Medicaid State Plan EPSDT Benefits under EHB 10: Pediatric services including oral and vision care. Base Benchmark Benefit that was Substituted: Eye Glasses for Children Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Medicaid State Plan EPSDT Benefits under EHB 10: Pediatric services including oral and vision care. Base Benchmark Benefit that was Substituted: Dental Check-Up for Children Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Medicaid State Plan EPSDT Benefits under EHB 10: Pediatric services including oral and vision care. OFFICIAL TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I

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Page 29 of 43 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Rehabilitative Speech Therapy Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Speech, hearing and Language Disorder Services under EHB 7: Rehabilitative and Habilitative Services. Base Benchmark Benefit that was Substituted: Rehabilitative Occupational and Physical Therapy Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Occupational Therapy and Physical Therapy under EHB 7: Rehabilitative and Habilitative Services. Base Benchmark Benefit that was Substituted: Well Baby Visits & Care Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Maternal Support Services under EHB 4: Maternity and Newborn Care. Base Benchmark Benefit that was Substituted: Laboratory Outpatient and Professional Services Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Laboratory and X-ray services under EHB 8: Laboratory Services. Base Benchmark Benefit that was Substituted: X-rays and Diagnostic Imaging Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Laboratory and X-ray services under EHB 8: Laboratory Services. Base Benchmark Benefit that was Substituted: Basic Dental Care - Child Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: OFFICIAL TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I

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Page 30 of 43 Alternative Benefit Plan Duplication: Covered under the North Carolina Medicaid State Plan as Medicaid State Plan EPSDT Benefits under EHB 10: Pediatric services including oral and vision care. Base Benchmark Benefit that was Substituted: Orthodontia - Child Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Medicaid State Plan EPSDT Benefits under EHB 10: Pediatric services including oral and vision care. Base Benchmark Benefit that was Substituted: Major Dental Care - Child Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Medicaid State Plan EPSDT Benefits under EHB 10: Pediatric services including oral and vision care. Base Benchmark Benefit that was Substituted: Transplant Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Duplication: Covered under the North Carolina Medicaid State Plan as Transplant and Related Services under EHB 3: Hospitalization. Base Benchmark Benefit that was Substituted: Infertility Services Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Coverage of infertility services is substituted by the current Medicaid state plan non-emergency medical transportation (NEMT) benefit. Base Benchmark Benefit that was Substituted: Well Baby Visits & Care Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Covered under the North Carolina Medicaid State Plan as Maternity Care – Physicians’ Services under EHB 4: Maternity and Newborn Care. OFFICIAL TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I

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Page 31 of 43 Alternative Benefit Plan Base Benchmark Benefit that was Substituted: Accidental Dental Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Covered under the North Carolina Medicaid State Plan as Dental Services under EHB 1: Ambulatory patient services Base Benchmark Benefit that was Substituted: Allergy Testing Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Covered under the North Carolina Medicaid State Plan as Physicians' Services under EHB 1: Ambulatory patient services Base Benchmark Benefit that was Substituted: Prosthetic Devices Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Covered under the North Carolina Medicaid State Plan as Prosthetic devices under EHB 7: Rehabilitative and Habilitative Services & Devices Base Benchmark Benefit that was Substituted: Infusion Therapy Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Covered under the North Carolina Medicaid State Plan as Home Health Services under EHB 1: Ambulatory Patient Services Base Benchmark Benefit that was Substituted: Reconstructive Surgery Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: Covered under the North Carolina Medicaid State Plan as Inpatient hospital services under EHB 3: Hospitalization Base Benchmark Benefit that was Substituted: Diabetes Education Source: Base Benchmark Remove Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits: OFFICIAL TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I I 1 1 I I

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Page 34 of 43 Alternative Benefit Plan 14. Other 1937 Covered Benefits that are not Essential Health Benefits Collapse All Other 1937 Benefit Provided: Optometrist Services Source: Section 1937 Coverage Option Benchmark Benefit Package Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: See other information box below Duration Limit: See below Scope Limit: See other information box below Other: See Attachment 3.1-A, 6.b, Optometrist Services (1) Routine eye exams and refractions are covered for recipients under 21 years of age once per year and for recipients 21 years of age and older once every two years, based on general medical practice as published in North Carolina Division of Medical Assistance’s Medicaid clinical coverage policies on the Division’s website. Additional routine eye exams and refractions may be authorized by the State Medicaid Agency, based on Medicaid clinical coverage policy and medical necessity. Other 1937 Benefit Provided: Adult dental services Source: Section 1937 Coverage Option Benchmark Benefit Package Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: See other information box below Duration Limit: See other information box below Scope Limit: See other information box below Other: See Attachment 3.1-A, 10, Dental services The services requiring prior approval are: complete dentures, partial dentures, complete and partial denture relines, orthodontic services, periodontal services, elective root canal therapy, and complex or extensive oral maxillo-facial surgical procedures. Other 1937 Benefit Provided: ICF-IID services Source: Section 1937 Coverage Option Benchmark Benefit Package Remove Authorization: Yes Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None OFFICIAL TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 IZl □ I I I I I I I 1 1 I 1 1 I I I I I I I I 1 1 I 1 1 I I I I I I I I 1 1 I 1 1

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OFFICIAL Alternative Benefit Plan State Name:INorth Carolina Transmittal Number: NC - 23 - 0029 Attachment 3.1-L-D 0MB Control Number: 09381148 Benefits Assurances ABP7 EPSDT Assurances If the target population includes persons under 21, please complete the following assurances regarding EPSDT. Otherv.•ise, skip to the Prescription Drug Coverage Assurances below. The alternative benefit plan includes beneficiaries under 21 years of age. [ZI The state/ten-ito1y assures that the notice to an individual includes a description of the method for ensuring access to EPSDT services (42 CFR 440.345). [ZI The state/ten-ito1y assures EPSDT services will be provided to individuals under 21 years of age who are covered under the state/ten-itory plan under section 1902(a)(10)(A) of the Act. Indicate whether EPSDT services will be provided only through an Alternative Benefit Plan or whether the state/ten-it01y will provide additional benefits to ensure EPSDT services: (e Through an Alternative Benefit Plan. (' Through an Alternative Benefit Plan with additional benefits to ensure EPSDT services as defined in 1905(r). Other Infonnation regarding how ESPDT benefits will be provided to participants under 21 years of age ( optional): Prescription Drng Coverage Assurances [ZI The state/ten-ito1y assures that it meets the minimum requirements for prescription dmg coverage in section 1937 of the Act and implementing regulations at 42 CFR 440.347. Coverage is at least the greater of one dmg in each United States Pha1macopeia (USP) catego1y and class or the same number of prescription dtugs in each catego1y and class as the base benchmark. [ZI The state/ten-ito1y assures that procedures are in place to allow a beneficiary to request and gain access to clinically approp1-iate prescription dtugs when not covered. [ZI The state/ten-ito1y assures that when it pays for outpatient prescription dmgs covered under an Alternative Benefit Plan, it meets the requirements of section 1927 of the Act and implementing regulations at 42 CFR 440.345, except for those requirements that are directly contrary to amount, duration and scope of coverage pe1mitted under section 1937 of the Act. [ZI The state/ten-ito1y assures that when conducting prior authorization of prescription dtugs under an Alternative Benefit Plan, it complies with p1for authorization program requirements in section 1927( d)(5) of the Act. Other Benefit Assurances [ZI The state/ten-ito1y assures that substituted benefits are actuarially equivalent to the benefits they replaced from the base benchmark plan, and that the state/ten-itory has actua1-ial certification for substituted benefits available for CMS inspection if requested by CMS. [ZI The state/ten-ito1y assures that individuals will have access to services in Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) as defined in subparagraphs (B) and (C) of section l 905(a)(2) of the Social Security Act. TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 1210112P~ 1 of2

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OFFICIAL Alternative Benefit Plan [ZI The state/ten-ito1y assures that payment for RHC and FQHC services is made in accordance with the requirements of section l 902(bb) of the Social Security Act. [ZI The state/ten-ito1y assures that it will comply with the requirement of section l 937(b )(5) of the Act by providing, effective Januaiy 1, 2014, to all Alternative Benefit Plan participants at least Essential Health Benefits as described in section l 302(b) of the Patient Protection and Affordable Care Act. [ZI The state/ten-ito1y assures that it will comply with the mental health and substance use disorder parity requirements of section l 937(b )(6) of the Act by ensuring that the financial requirements and treatment limitations applicable to mental health or substance use disorder benefits comply with the requirements of section 2705(a) of the Public Health Service Act in the same manner as such requirements apply to a group health plan. [ZI The state/ten-ito1y assures that it will comply with section 1937(b)(7) of the Act by ensuring that benefits provided to Alternative Benefit Plan pa1t icipants include, for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section. [ZI The state/ten-ito1y assures transpo1tation (emergency and non-emergency) for individuals enrolled in an Alternative Benefit Plan in accordance with 42 CFR 431. 53. [ZI The state/ten-ito1y assures, in accordance with 45 CFR 156.l 15(a)(4) and 45 CFR 147.130, that it will provide as Essential Health Benefits a broad range of preventive services including: "A" and "B" services recommended by the United States Preventive Services Task Force; Adviso1y Committee for Immunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults recommended by HRSA's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (IOM). PRA Disclosure Statement According to the Pape1work Reduction Act of 1995, no persons ai·e required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this info1mation collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instrnctions, 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, Ma1yland 21244-1850. TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 V.20160722 Effective Date: 1210112P~ 2 of2

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State Name: !North Carolina Transmittal Nlllllber: NC - 23 - 0029 Service Delivery Systems OFFICIAL Alternative Benefit Plan Attachment 3.1-L-D 0MB Control Nlllllber: 0938-1148 ABP8 Provide detail on the type of delive1y system(s) the state/tel1'ito1y will use for the Alternative Benefit Plan's benchmark benefit package or benchmark-equivalent benefit package, including any variation by the participants' geographic area. Type of service delive1y system(s) the state/ten'it01y will use for this Alternative Benefit Plan(s). Select one or more service delive1y systems: IZ! Managed care. ~ Managed Care Organizations (MCO). IZ! Prepaid Inpatient Health Plans (PIHP). 0 Prepaid Ambulato1y Health Plans (PAHP). IZ! Primary Care Case Management (PCCM). IZ! Fee-for-service. D Other service delive1y system. Managed Care Options Managed Care Assurance [{] The state/ten'it01y certifies that it will comply with all applicable Medicaid laws and regulations, including but not limited to sections 1903(m), 1905(t), and 1932 of the Act and 42 CFR Pait 438, in providing managed care services through this Alternative Benefit Plan. This includes the requirement for CMS approval of contracts and rates pursuant to 42 CFR 438.6. Managed Care Implementation Please describe the implementation plan for the Alternative Benefit Plan under managed care including member, stakeholder, and provider outreach effo11s. The MCOs, PIHPs, and PCCMes will offer the same benefit package to expansion members as other enrolled members, and have demonstrated to the NC through testing and readiness reviews their successful implementation of that benefit package for the new populations. The MCOs, PIHPs, and PCCMes will educate members on the ABP through their member welcome packet and handbook which includes a description of covered services. Additionally, the Department has published fact sheets and other provider and stakeholder mate1-ials for distribution through webinars, presentations, paid media, and social media outreach to ensure info1mation is available on the benefits provided to the expansion population. MCO: Managed Care Organization The managed care delive1y system is the same as an already approved managed care program. The managed care program is operating under (select one): ("' Section 1915(a) voluntaiy managed cai·e program. l Section 1915(b) managed care waiver. ("' Section 1932(a) mandato1y managed care state plan amendment. (e Section 1115 demonstration. Supersedes: NEW Page 1 of3

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OFFICIAL Alternative Benefit Plan (' Section 1937 Alternative (Benchmark) Benefit Plan state plan amendment. Identify the date the managed care program was approved by CMS: !Jul 7, 2023 Describe program below: Through its Section 1115 demonstration, the State has approval to implement comprehensive managed care using a combination of plans: (1) Standard plans for most enrollees, except those in excluded populations, individuals in exempt populations who choose not to enroll, or enrollees in BH I/DD Tailored Plans or Specialized Plans. Standard plans cover physical health and most behavioral health services, other than those specialized behavioral health services only available through a BH I/DD Tailored Plan. (2) BH I/DD Tailored Plans for individuals with complex behavioral health needs, I/DD and TBI, covering all benefits, including specialized behavioral health services. (3) Specialized Foster Care Plan for individuals in foster care and former foster youth. See the State's 1115 demonstration for more details on eligibility, benefits, and timelines for when products will take effect. Additional Information: #type# (Optional) Provide any additional details regarding this service delive1y system (optional): I PIBP: Prepaid Inpatient Health Plan The managed care delive1y system is the same as an already approved managed care program. The managed care program is operating under (select one): (' Section 1915(a) voluntaiy managed cai·e program. (e Section 1915(b) managed care waiver. (' Section 1115 demonstration. (' Section 1937 Alternative (Benchmark) Benefit Plan state plan amendment. Identify the date the managed cai·e program was approved by CMS: 106/28/2023 Describe program below: EJ Individuals not enrolled in an MCO receive their behavioral health services and 1915( c) Innovations and TBI waiver services (if eligible) through a PIHP, administered by Local Management Entity Managed Care Organizations (LME MCOs). There is one LME MCO available per region. See approved 1915(b) waiver for additional details Additional Information: #type# (Optional) Provide any additional details regai·ding this service delive1y system (optional): I PCCM: P1i mary Ca1·e Case Management The PCCM delive1y system is the same as an already approved PCCM program. The managed care program is operating under (select one): (' Section 1915(b) managed care waiver. (e Section 1932(a) mandato1y managed care state plan amendment. - ........ ---· ............. 11 / 1....-. EJ .. 11'111,i,"'- IW'l,i, ... 'Ml .. 'l,i,'• l•/ V I '•V•V I I 1 n: ""' -';s•uu~;:i, Supersedes: NEW Page 2 of3

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OFFICIAL Alternative Benefit Plan (' Section 1115 demonstration. (' Section 1937 Alternative (Benchmark) Benefit Plan state plan amendment. Identify the date the managed care program was approved by CMS: 1Aug3, 2023 I Describe program below: The State has two PCCM programs: (1) Collllllunity Care ofN01th Carolina (CCNC). CCNC serves as the primary care case management entity for all populations not cmTently enrolled in an MCO, other than those enrolled in the Tribal Option. (2) Tribal Option. The Eastern Band of Cherokee Indians (EBCI) has created a prima1y care case management entity (refe1Ted to as the EBCI Tribal Option) available for all IHS eligibles and federally recognized tribal members residing within a defined service area. For additional details on enrollment and eligibility, please see the approved SP As. Tribe Option was approved by CMS on 9/13/21. CCNC was most recently approved by CMS on 8/3/23. Additional Information: #type# (Optional) Provide any additional details regarding this service delive1y system (optional): I I Fee-For-Service Options Indicate whether the state/ten-ito1y offers traditional fee-for-service and/or services managed under an administrative services organization: (i' Traditional state-managed fee-for-service (' Services managed under an administrative services organization (ASO) a1rnngement Please desc1-ibe this fee-for-service delive1y system, including any bundled payment a1rnngements, pay for perfonnance, fee-for- service care management models/non-risk, contractual incentives as well as the population served via this delive1y system. Individuals who are not cmTently enrolled in an MCO receive their physical health services through fee-for-service. I Additional Information: Fee-For-Service (Optional) Provide any additional details regarding this service delive1y system (optional): I PRA Disclosure Statement According to the Pape1work Reduction Act of 1995, no persons are required to respond to a collection of info1mation unless it displays a valid 0MB control number. The valid 0MB control number for this info1mation collection is 0938-1148. The time required to complete this info1mation collection is estimated to average 5 homs per response, including the time to review instiuctions, search existing data resomces, gather the data needed, and complete and review the info1mation collection. If you have collllllents concerning the accmacy of the time estimate(s) or suggestions for improving this form, please wi-ite to: CMS, 7500 Secw-ity Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Ma1yland 21244-1850. TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 Effective Date: 12/01/2023 V.20181119 Page 3 of3

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OFFICIAL Alternative Benefit Plan State Name:INorth Carolina Transmittal Number: NC - 23 - 0029 Attachment 3.1-L-D 0MB Control Number: 09381148 General Assurances ABP10 Economy and Efficiency of Plans [Z] The state/ten-ito1y assures that Altemative Benefit Plan coverage is provided in accordance with Federal upper payment limit requirements and other economy and efficiency principles that would otherv.•ise be applicable to the services or delive1y system through which the coverage and benefits are obtained. Economy and efficiency will be achieved using the same approach as used for Medicaid state plan services. Compliance with the Law [Z] The state/ten-ito1y will continue to comply with all other provisions of the Social Security Act in the administration of the state/ten-itory plan under this title. [Z] The state/ten-ito1y assures that Altemative Benefit Plan benefits designs shall conform to the non-discrimination requirements at 42 CFR 430.2 and 42 CFR 440.347(e). [Z] The state/ten-ito1y assures that all providers of Altemative Benefit Plan benefits shall meet the provider qualification requirements of the Base Benchmark Plan and/or the Medicaid state plan. PRA Disclosure Statement According to the Pape1work Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this info1mation collection is 0938-1148. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instmctions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments conceming 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, Ma1yland 21244-1850. TN: NC 23-0029 Supersedes: NEW Approval Date: 11/14/2023 V.20160722 Effective Date: 1210112P~ 1 of I

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CMS-PM-10120 ··· · ••• ••• ••••••• • •••••• ••••••• • ••• ••• ••••••• •••• ••••••••••• ••• ••• ········ ····ATTACHMENT 3.1-F (Part2) Date: [TBD] ··· ····· ·········· .. ........ ... ............. .. ........... .. ....................... ............. ..... Page 6 •••••• •••••••••• ••••••• •• •••• •••••••••••• ••••••••• •••••••••••••••••••••••• •• •• ••• •••• •• ••• ••••••• •• ••••••••••• OMB No.: 0938-933 State: North Carolina A. Mandato1-y Eligibility Gt'oups (Eligibility Groups to which a state must pt'ovide Medicaid coverage) 1. Family/Adult Eligibility Group 1. Parents and Other Caretaker Relatives 2. Pregnant Women 3. Children Under Age 19 (Inclusive of Deemed Newborns under §43 5.117) 4. Fonner Foster Care Youth (up to age 26) 5. Adult Group (Non-pregnant individuals age 19-64 not eligible for Medicare with income no more than 133% FPL) 6. Transitional Medical Assistance (Includes adults and children, if not eligible under §435.116, §435.118, or §435.119) 7. Extended Medicaid Due to Spousal Suppo1t Collections TN No. 23-0032 Supersedes TNNo. 21-0011 ~ itation M V E pugubtion (42 ~FRI or SSA) §435.110 IX §435.116 IX §435.118 IX §435.150 DC §435.119 ~ 1902(a)(52), DC 1902(e)(l), 1925, ~nd 193l(c)(2) of $SA §435.115 DC Approval Date: 11/15/2023 Geographic Area Notes (include specifics if M/V/E varies bv area) Cherokee, Graham, Tribal members IHaywood, Jackson and other IHS and Swain Counties. eligible !beneficiaries from Buncombe, Clay, Henderson, Macon, Madison and Transylvania counties may also opt-in. Tribal members and other IHS eligible !beneficiaries are exempt from managed care and may request disenrolhnent from the Tribal Option PCCM entity at any time iupon request to the Department and/or its Vendor 1Pa11ners. Cherokee, Graham, Same as Row A.1 !Haywood, Jackson and Swain Counties. Cherokee, Graham, Same as Row A 1 !Haywood, Jackson and Swain Counties. Cherokee, Graham, Same as Row A 1 !Haywood, Jackson and Swain Counties. ~herokee, Graham, Same as Row A 1 !Haywood, Jackson ~nd Swain Counties. Cherokee, Graham, Same as Row A 1 IHaywood,Jackson and Swain Counties. Cherokee, Graham, Same as Row A 1 IHaywood, Jackson and Swain Counties. Effective Date: 12/01/2023

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Medicaid Premiums and Cost Sharing State Name: !North Carolina Transmittal Number: NC -23 - 0042 0MB Control Number: 0938-1148 Cost Sharing Requirements 1916 1916A 42 CFR 447.50 tlu-ough 447.57 (excluding 447.55) The state charges cost sharing (deductibles, co-insurance or co-payments) to individuals covered under Medicaid. 0 ll1e state assures that it administers cost sharing in accordance with sections 1916 and 1916A of the Social Security Act and 42 CFR 447.50 tl1rough 447.57. General Provisions 0 The cost sharing amounts established by the state for services are always less thau the amount the agency pays for the service. [j] No provider may deny services to an eligible individual on account of the individual's inability to pay cost sharing, except as elected by the state in accordance with 42 CFR 447.52(e)(l). 00 The process used by the state to inform providers whether cost sharing for a specific item or service may be imposed on a beneficiary and whether the provider may require the beneficiary to pay the cost sharing charge, as a condition for receiving the item or service, is (check all that apply): [gJ The state includes an indicator in tJ1e Medicaid Management Infonnation System (MMIS) D The state includes an indicator in the Eligibility and Enrollment System D The state iucludes an indicator in the Eligibility Verification System D The state includes an indicator on the Medicaid card, which the beneficiary presents to the provider [gJ Other process Description: The state provides billing guidance to providers and MCOs that is incorporated by reference. [j] Contracts with managed care organizations (MCOs) provide that any cost-sharing charges the MCO imposes on Medicaid enrollees are in accordance with the cost sharing specified in the state plan and the requirements set forth in 42 CFR 447.50 through 447.57. Cost Sharing for Non-Emergency Services Provided in a Hospital Emergency Department The state imposes cost sharing for non-emergency services provided in a hospital emergency department. 0 The state ensures that before providing non-emergency services and imposing cost sharing for such services, that the hospitals providing care: TN: N C -23-0042 Supersedes: N C -22-0020 Approval Date: 02/23/2024 Effective Date: 11/01/2023 Page 1 of3

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Medicaid Premiums and Cost Sharing [!] Conduct an appropriate medical screening under 42 CFR 489.24, subpart G to determine that the individual does not need emergency services; [!] Infonn the individual of the amount of his or her cost sharing obligation for non-emergency services provided in the emergency department; [!] Provide the individual with the name and location of an available and accessible alternative non-emergency services provider; [!] Determine that the alternative provider cau provide services to the individual in a timely manner with the imposition of a lesser cost shariug amount or no cost sharing if the individual is otherwise exempt from cost sharing; and [!] Provide a referral to coordinate scheduling for treatment by the alternative provider. 0 The state assures that it has a process in place to identify hospital emergency department services as non-emergency for purposes of imposing cost sharing. This process does not limit a hospital's obligations for screening and stabilizing treatment of an emergency medical condition under section 1867 of the Act; or modify any obligations under either state or federal standards relating to the application of a prndent-layperson standard for payment or coverage of emergency medical services by any managed care organization. TI1e process for identifying emergency department services as non-emergency for purposes of imposing cost sharing is: 111e state maintains a list of codes that will be periodically updated. Cost Sharing for Drugs 1·11e state charges cost sharing for dmgs. The state has established differential cost sharing for preferred and non-preferred dmgs. [!] All drugs will be considered preferred drngs. Beneficiary and Public Notice Requirements 0 Consistent with 42 CFR 447.57, the state makes available a public schedule describing current cost sharing requirements in a manner that ensures that affected applicants, beneficiaries and providers are likely to have access to the notice. Prior to submitting a SPA which establishes or substantially modifies existing cost sharing amounts or policies, the state provides the public with advance notice of tJ1e SPA, specifying the amount of cost sharing and who is subject to the charges, and provides reasonable opportunity for stakeholder comment. Documentation demonstrating that the notice requirements have been met are submitted with the SPA. l11e state also provides opportunity for additional public notice if cost sharing is substantially modified during the SPA approval process. Other Relevant Information The State has copayments for covered Outpatient Pharmacy medications for adults (2 l and older) in the traditional Medicaid program. Those copayments are $4 per prescription. Groups of Individuals who are mandatorily exempt from cost sharing as described in section G3 have $0 co-payment for all prescriptions. Additionally, antiretroviral medications used to treat HIV for the purpose of reducing viral load are not subject to copayments. TN: NC-23-0042 Supersedes: NC-22-0020 Approval Date: 02/23/2024 Effective Date: 11/01/2023 Page 2 of3

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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 June 21, 2024 Jay Ludlum, Deputy Secretary North Carolina Medicaid NC Department of Health and Human Services Division of Health Benefits 1985 Umstead Drive, Kirby Building Raleigh, NC 2703 RE: North Carolina 1915(c) Waiver Renewal for NC-0423.R04 | 1915(c) Waiver Amendment for NC-1326.R01.05 | State Plan Amendment NC-24-0018 for §1915(i) Home and Community- Based Services (HCBS) benefit | 1915(b) Waiver Renewal for NC-0002.R06 Dear Deputy Secretary Ludlum: The Centers for Medicare & Medicaid Services (CMS) is approving request to renew its 1915(c) Innovations HCBS waiver and amend its 1915(c) Traumatic Brain Injury (TBI) HCBS waiver. The TBI waiver serves individuals with traumatic brain injuries who require Hospital or Nursing Facility Level of Care. The Innovations waiver serves individuals with Intellectual and Developmental Disabilities (I/DD) who require an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) Level of Care. These waivers are assigned the following CMS Control Numbers: NC-1326.R01.05 (TBI amendment) and NC- 0423.R04 (Innovations), which should be referenced in all future correspondence relating to these waivers. In accordance with 42 CFR 423.910, states submit Medicare Modernization Act (MMA) files to CMS to, among other things, ensure that dually eligible individuals have the correct cost sharing amounts for the Medicare Part D prescription drug coverage. Participants in 1915(c) waivers qualify for $0 copays for Medicare Part D drugs. To ensure cost sharing is accurate, it is - eligible participants in this waiver. This indicator is what initiates $0 copays for Medicare Part D drugs. More information is in chapter 6 of the MAPD State User Guide. The 1915(c) Innovations waiver will offer the following services: Assistive Technology, Benefits Counseling, Community Living and Support, Community Navigator, Community Networking, Community Transition, Crisis Services, Day Supports, Financial Support Services, Home Delivered Meal, Home Modifications, Individual Goods and Services, Natural Supports Education, Residential Supports, Respite, Specialized Consultation, Supported Employment, Supported Living, Supported Living-Periodic, Supported Living-Transition, and Vehicle Modifications.

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Deputy Secretaiy Ludlum letter Page 2 The following estimates of utilization and cost have been approved: Waiver Year Unduplicated Average Cost per Recipients Participant (Factor D) WYl 7/01/24-6/30/25 14,752 $ 11,158.00 WY2 7/01/25-6/30/26 14,736 $ 11,552.00 WY3 7/01/26-6/30/27 14,736 $ 11,959.00 WY4 7/01/27-6/30/28 14,736 $12,381.00 WY5 7/01/28-6/30/29 14,736 $ 12,817.00 Total Waiver Costs $ 1310313229 .44 $ 1346886380.52 $ 1384734758.47 $ 1423823982.44 $ 1464162184.93 CMS is also concurrently approving North Carolina's request to amend its state plan to revise its 1915(i) HCBS benefit, transmittal number 24-0018, titled Mental Health/Individuals with Developmental Disabilities/Substance Use Disorder (SUD). CMS conducted the review of the state's submittal according to statutory requirements in Title XIX of the Social Security Act and relevant federal regulations. Enclosed is a copy of the approved state plan amendment (SP A). It is important to note that CMS' approval of the 1915(c) waiver renewal, 1915(c) waiver amendment, and the amended 1915(i) HCBS state plan benefit solely addresses the state's compliance with the applicable Medicaid authorities. CMS' approval does not address the state's independent and separate obligations under federal laws including, but not limited to, the Americans with Disabilities Act, Section 504 of the Rehabilitation Act, or the Supreme Court's Olmstead decision. Guidance from the Department of Justice concerning compliance with the Americans with Disabilities Act and the Olmstead decision is available at http://www.ada.gov/olmstead/g&a olmstead.htm. ConcmTently, CMS is approving North Carolina's request to renew its 1915(b) Waiver, CMS Control Number NC-0002.R06, titled NC Mental Health, Developmental Disabilities and Substance Abuse Services (MH/IDD/SAS) Health Plan. This waiver allows No1ih Carolina to mandate emollment of individuals into the state's Prepaid Inpatient Health Plans (PIHPs) for certain mental health and substance abuse services and HCBS approved under the TBI and Innovations waivers. This waiver also allows No1ih Cai·olina to deliver Health Home Tailored care management and the 1915(i) HCBS benefit through the PIHP delive1y system. This managed care program is authorized under sections 1915(b)(l), 1915(b)(3), and 1915(b)(4) of the Social Security Act (the Act) and provides a waiver of the following sections of Title XIX: • Section 1902(a)(l) Statewideness for the TBI waiver only • Section 1902(a)(10)(B) Comparability of Services • Section 1902( a)(23) Freedom of Choice • Section 1902(a)(4) to permit the State to mandate beneficiaries into a single PIHP and restrict disemollment Om decision is based on the evidence submitted to CMS demonstrating that the state's proposal is consistent with the pm-poses of the Medicaid program, will meet all of the statuto1y and regulato1y requirements for assming beneficiaries' access to and quality of se1vices, and will be a cost-effective means of providing se1vices to emollees under this waiver; and agreement from

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1-i: Page 4 Supersedes: 22-0026 4. Distribution of State plan HCBS Operational and Administrative Functions. [2] (By checking this box the state assures that): When the Medicaid agency does not directly conduct an administrative function, it supe1vises the perfonnance of the function and establishes and/or approves policies that affect the function. All functions not perfonned directly by the Medicaid agency must be delegated in wiiting and monitored by the Medicaid Agency. When a function is pe1fo1med by an agency/entity other than the Medicaid agency, the agency/entity perfonning that function does not substitute its own judgment for that of the Medicaid agency with respect to the application of policies, rnles and regulations. Fmthennore, the Medicaid Agency assures that it maintains accountability for the pe1formance of any operational, contractual, or local regional entities. In tl1e following table, specify the entity or entities that have responsibility for conducting each of the operational and administrative functions listed (check each that applies): (Check all af!encies and/or entities that verform each function): Other State Medicaid Operating Contracted Local Non- Function Agency Agency Entity State Entity 1 hldividual State plan HCBS enrollment 0 □ 0 2 Eligibility evaluation 0 □ □ 3 Review of pa1ticipant se1vice plans 0 □ 0 4 Prior authorization of State plan HCBS 0 □ 0 5 Utilization management 0 □ 0 6 Qualified provider enrollment 0 □ □ 7 Execution of Medicaid provider agreement 0 □ □ 8 Establishment of a consistent rate 0 □ 0 methodology for each State plan HCBS 9 Rules, policies, procedures, and info1mation development governing the State 0 □ □ plan HCBS benefit 1 OQuality assurance and quality improvement 0 □ 0 activities (Specify, as numbered above, the agencies/entities (other than the SMA) that perform each function): Tailored Plan/PIHPs perfonn these activities under a contract with the State Medicaid agency. 1. Individual State Plan HCBS emollment 3. Review of paiticipant se1vice plans 4. Prior autl1orization of State plan HCBS 5. Utilization management 8. Establishment of a consistent rate methodology for each State Plan HCBS 10. Quality assurance and quality improvement activities. □ □ □ □ □ □ □ □ □ □

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 (By checking the following boxes the State assures that): State plan Attachment 3 .1-i: Page 5 Supersedes: 22-0026 5. IEl Conflict of Interest Standards. The state assures the independence of persons perfom1ing evaluations, assessments, and plans of care. W1itten conflict of interest standards ensure, at a minimum, that persons pe1fomling these functions are not: • related by blood or maiTiage to the individual, or any paid cai·egiver of the individual • financially responsible for the individual • empowered to make finai1cial or health-related decisions on behalf of the individual • providers of State plan HCBS for the individual, or those who have interest in or are employed by a provider of State plan HCBS; except, at the option of the state, when providers ai·e given responsibility to perform assessments and plans of care because such individuals are the only willing and qualified entity in a geographic area, and the state devises conflict of interest protections. (If the state chooses this option, specify the corifhct of interest protections the state will implement): For T1ibal members who are exempt from emollment in integrated Medicaid managed cai·e, the State will allow the Cherokee Indian Hospital Authority (CIHA) or their delegated Tiibal entity to conduct assessment and care planning, although CIHA may also provide se1vices to the members. CIHA or their delegated Tribal entities ai·e the only entities that have willing and qualified providers with experience and knowledge to provide se1vices to individuals who share a cormnon language or cultural background. Individuals providing care management and services will not work in the same unit. Individuals providing care management will not be: • Related by blood or maniage to the individual, or any paid caregiver of the individual • Financially responsible for the individual • Empowered to make financial or health-related decisions on behalf of the individual Additionally, care managers may not supervise individuals providing 1915(i) services, and utilization managers ai1d cai·e managers may not be supervised by the same supe1visor or manager. Tiibal members will be provided with information explaining that it is their choice to use CIHA or their delegated Tiibal entity ai1d that independent cai·e managers and service providers are available if they do not believe they need the colllinon language/cultural background which only the CIHA or their delegated Tribal entity can provide. 6. IEl Fair Hearings and Appeals. The state assures that individuals have opportunities for fair hearings and appeals in accordance with 42 CFR 431 Subpa1t E. 7. IEl No FFP for Room and Board. The state has methodology to prevent claims for Federal financial pa1ticipation for room ai1d board in State plan HCBS. 8. IEl Non-duplication of services. State plan HCBS will not be provided to an individual at the same time as another service that is the saine in nature and scope regai·dless of source, including Federal, state, local, and private entities. For habilitation se1vices, the state includes within the record of each individual an explanation that these se1vices do not include special education and related services defined in the Individuals with Disabilities Education Improvement Act of 2004 that otherwise are available to the individual through a local education agency, or vocational rehabilitation se1vices that otherwise are available to the individual through a pro grain fonded under § 110 of the Rehabilitation Act of 1973.

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State plan Attachment 3 .1-i: State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 Page 6 Supersedes: 22-0026 Number Served 1. Projected Number ofUnduplicated Individuals To Be Served Annually. (Specify for year one. Years 2-5 optional): Annual Period From To Projected Number of Participants Year 1 7/1/23 6/30/24 10,364 Year 2 7/1/24 6/30/25 Year 3 7/1/25 6/30/26 Year 4 7/1/26 6/30/27 Year 5 7/1/27 6/30/28 2. IEl Annual Reporting. (By checking this box the state agrees to): annually report the actual number of unduplicated individuals se1ved and the estimated number of individuals for the following year. Financial Eligibility 1. IE] Medicaid Eligible. (By checking this box the state assures that): Individuals receiving State plan HCBS are included in an eligibility group that is covered under the State's Medicaid Plan and have income that does not exceed 150% of the Federal Pove1ty Line (FPL). (This election does not include the optional categorically needy eligibility group specified at § l 902(a)(l O)(A)(ii)(XXII) of the Social Secmity Act. States that want to adopt the § l 902(a)(l O)(A)(ii)(XXII) eligibility catego1y make the election in Attachment 2.2-A of the state Medicaid plan.) 2. Medically Needy (Select one): D The State does not provide State plan HCBS to the medically needy. IE] The State provides State plan HCBS to the medically needy. (Select one): D The state elects to disregard the requirements section of 1902(a)(l O)(C)(i)(III) of the Social Secmity Act relating to community income and resource rules for the medically needy. When a state makes this election, individuals who qualify as medically needy on the basis of this election receive only l 9 l 5(i) services. IEl The state does not elect to disregard the requirements at section 1902(a)(IO)(C)(i)(III) of the Social Security Act. Evaluation/Reevaluation of Eligibility 1. Responsibility for Performing Evaluations / Reevaluations. Eligibility for the State plan HCBS benefit must be detennined through an independent evaluation of each individual). Independent evaluations/reevaluations to determine whether applicants are eligible for the State plan HCBS benefit are pe1fonned (Select one): ! 0 ! Directly by the Medicaid agency

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1-i: Page 7 Supersedes: 22-0026 By Other (specify State agency or entity under contract with the State Medicaid agency): 2. Qualifications of Individuals Performing Evaluation/Reevaluation. The independent evaluation is perfonned by an agent that is independent and qualified. There are qualifications (that are reasonably related to pe1fo1ming evaluations) for the individual responsible for evaluation/reevaluation of needs based eligibility for State plan HCBS. (Specify qualifications): The minimum qualifications for individuals perfonning evaluations/reevaluations are that these individuals meet No1th Carolina's definition of a Qualified Professional: • An individual who holds a license, provisional license, ce1tificate, registration or pennit issued by the governing board regulating a hmnan service profession, except a registered nurse who is licensed to practice in the State ofN01th Carolina by the No1th Carolina Board of Nursing who also has four years of full-time accumulated experience in mental health, developmental disabilities and substance abuse services (mh/dd/sa) with the population served; or • A graduate of a college or university with a Master's degree in a human service field and has one year of full-time accumulated mh/dd/sa experience with the population served, or a substance abuse professional who has one year of full-time accumulated supe1vised experience in alcoholism and drug abuse counseling; or • A graduate of a college or university with a bachelor's degree in a human se1vice field and has two years of full-time accumulated mh/dd/sa experience with the population se1ved, or a substance abuse professional who has two years of full-time accumulated supervised experience in alcoholism and drug abuse counseling; or • A graduate of a college or university with a bachelor's degree in a field other than human se1vices and has four years of full-time accumulated mh/dd/sa experience with the population served, or a substance abuse professional who has four years of full-time accumulated supe1vised experience in alcoholism and drug abuse counseling. 3. Process for Performing Evaluation/Reevaluation. Desc1ibe the process for evaluating whether individuals meet the needs-based St.ate plan HCBS eligibility c1iteria and any instnnnent(s) used to make this dete1mination. If the reevaluation process differs from the evaluation process, describe the differences: The individual will be refeITed for assessment to an organization conducting care management either the Tailored Plan/PIHP, a care management agency (behavioral health or I/DD provider certified by the State), or an AMH+ practice (piima1y care provider ce1tified by the State) or, if a Tribal member, the CIHA. The individual must have a 1915(i) assessment completed prior to 1915(i) emollment. The State will conduct a brief evaluation to dete1mine if an individual meets eligibility criteiia (needs-based Iisk c1iteria, targeting criteria, and financial c1ite1ia, including confi1ming that the individual's income does not exceed 150% of the FPL). This evaluation will be at the initial request, and reevaluation will be done during the individual's bi.Ith month.

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1-i: Page 8 Supersedes: 22-0026 4. [El Reevaluation Schedule. (By checking this box the state assures that): Needs-based eligibility reevaluations are conducted at least eve1y twelve months. 5. [El Needs-based HCBS Eligibility Criteria. (By checldng this box the state assures that): Needs-based critetia are used to evaluate and reevaluate whether an individual is eligible for State plan HCBS. The ciite1ia take into account the individual's support needs, and may include other 1isk factors: (Specify the needs-based criteria): Need for supp01t in acquhing, maintaining, and retaining skills needed to live and work in the community, as evidenced by at least one functional deficit in ADLs, IADLs, social and/or work skills. 6. [El Needs-based Institutional and Waiver Criteria. (By checking this box the state assures that): There are needs-based criteria for receipt of institutional se1vices and pa1ticipation in ce1tain waivers that are more stiingent than the criteria above for receipt of State plan HCBS. If the state has revised institutional level of care to reflect more stringent needs-based criteria, individuals receiving institutional se1vices and paiticipating in ce1tain waivers on the date that more stringent ctiteria become effective are exempt from the new c1ite1ia until such time as they no longer require that level of cai·e. (Complete chart below to summari=e the needs-based criteria for State Plan HCBS and corresponding more-stringent criteria for each of the following institutions): State plan HCBS NF (& NF LOC** waivers) ICF/IID (& ICF/IID LOC Applicable Hospital* needs-based eligibility waivers) ( & Hospital LOC criteria waivers) Need for suppo1t 1. Need for services, by physician's In order to be Medicaid-certified at The NC IBI Level of Care in acquhing, judgment, requiring: an ICF/IID level of care, a Assessment tool is used to A. Supervision of a registered beneficiary shall meet the determine the initial Level Of maintaining, nurse (RN) or licensed following criteria: Care (LOC). and/or retaining practical nurse (LPN); and 1. Require active treatment B.Otherpersonnelworlcing necessitating the ICF/IID level For Specialty Hospital Level skills needed to under the direct supervision of care; and of Care, the following must of an RN or LPN. live and work in 2. Observation and assessment of 2. Have a diagnosis of Intellectual be met: the community, as beneficiary needs by an RN or Disability per the Diagnostic 1. Behavior Assessment Grid LPN. The nursing services must and Statistical Manual on indicates impairment that is evidenced by at be intensive and directed to an Mental Disorders, fifth edition, present and severe AND least one acute episode or a change in the text (DSM-5), or a condition requires the availability of functional deficit treatment plan that requires such that is closely related to mental intensive behavior concentrated monitoring. retardation. intervention in two or more in ADLs, IADLs, 3. Restorative nursing measures i. Intellectual Disability is a of the following areas: social and/or work once a beneficiary's medical disability characterized by damage to property, condition becomes stable as significant limitations both inappropriate sexual skills. noted in the treatment plan. in general intellectual activity, injury to others, Restorative nursing measures are used to maintain or restore function resulting in, or injury to self, physical maximum function or to prevent associated with, deficits or aggression; advancement of progressive impairments in adaptive 2. Behavioral support at one disability as much as possible. behavior. The disability of the following levels: Restorative nursing measures manifests before age 18. • Needs and receives are: ii. Persons with closely related occasional staff A. A coordinated plan that conditions refers to intervention in the form assists an active beneficiary individuals who have a of cues because the in achieving independence in severe, chronic disability person is anxious, activities of daily living, that meets ALL of the irritable, lethargic or bathing, eating, toileting, following conditions: demanding. Person dressing, transfer, and A. is attributable to: responds to cues.

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/2 1/2024 ambulation; B. Use of preventive measures or devices to prevent or delay the development of contractures, such as positioning, alignment, range of motion, and use of pillows; C. Ambulation and gait training with or without assistive devices; or D. Assistance with or supervision of the transfer, so the beneficiary would not necessarily require skilled nursrng care. 4. Dialysis (hemodialysis or peritoneal dialysis) as part ofa maintenance treatment plan. S. Treatment for a specialized therapeutic diet (physician prescribed). Documentation must address the specific plan of treatment, such as the use of dietary supplements, therapeutic diets, and frequent recording of the participant's nutritional status. 6. Administration or control of medication as required by State law to be the exclusive responsibility of the licensed nurse: A. Drugs requiring intravenous, hypodermoclysis, or nasogastric tube administration; B. The use of drugs requiring close observation during an initial stabilization period or requiring nursing skills or professional judgment on a continuous basis; or C. Frequent injections requiring nursing skills or professional judgment. 7. N asogastric or gastrostomy feedings requiring supervision and observation by an RN or LPN: A. Primary source of nutrition by daily bolus or continuous feedings; B. Medications administered through the tube; C. When beneficiary on dysphagia diet, pureed diet, or soft diet with thickening liquids; and D. Tube with flushes. 8. Respiratory therapy: oxygen as a temporary or intermittent therapy, or for a beneficiary who receives oxygen continuously as a component to a stable treatment plan: A. Nebulizer usage; B. Nasopharyngeal or tracheal suctioning; C. Oral suctioning; and D. Pulse oximetry. 9.Isolation when medically necessary as a limited measure because of a contagious or infectious disease. 10. Woundcareofdecubitus ulcers State plan Attachment 3 .1- i: Page 9 Supersedes: 22-0026 i. Cerebral palsy or "Occasional" is defined epilepsy; or as less than four times ii. any other condition, per week The person other than mental needs and receives illness, found to be regular staff intervention closely related to in the form of mental retardation redirection because the because this person has episodes of condition results in disorientation, impairment of hallucinates, wanders, is general intellectual withdrawn or exhibits functioning or similar behaviors. adaptive behavior Person may be resistive similarto that of but responds to Intellectually redirection. "Regular" is Disabled persons, defined as four or more and requires times per week. treatment or • Needs and receives services similar to behavior management those required for and staff intervention these persons; because person exhibits B. The related condition disruptive behavior such manifested before age 22; as verbally abusing C. Is likely to continue others, wandering into indefinitely; and private areas, removing D. Have Intellectual or destroying property, Disability or a related or acting in a sexually condition resulting in aggressive manner. substantial functional Person may be resistant limitations in three or to redirection. more of the following • Needs and receives major life activity areas behavior management (refer to Attachment B): and staff intervention i. Self-Care (ability to because person is take care of basic life physically abusive to self needs for food, and others. Person may hygiene, and physically resist appearance); redirection. ii. Understanding and 3.Requires services and/or use of language supports that exceed services (ability to both inTBIW-NF. understand others and 4. Requires a 24-hour plan of to express ideas or care that includes a formal behavioral support plan. 5. information to others Requires LOC and either verbally or behavioral support nonverbally); available in a iii. Leaming ( ability to neurobehavioral hospital; acquire new available intensive behavior behaviors, intervention. A person does perceptions, and not have to be a resident of a neurobehavioral hospital to information, and to require this LOC. apply experiences to new situations); iv. Mobility (ambulatory, semi- ambulatory, non- ambulatory); "· Self-Oirection (managing one's social and personal life, and ability to make decisions necessary to protect one's life); vi. Capacity for independent living ( age-appropriate ability to live without extraordinary

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 managed in the community setting). 2. Category II: (One or more conditions from both Category I and II) A. Need for teaching and counseling related to a disease process, disability, diet, or medication. B. Adaptive programs: re- training the beneficiary to reach his or her maximum potential ( such as bowel and bladder training or restorative feeding); documentation must report the purpose of the beneficiary's participation in the program and document the beneficiary's progress. C. Factors to consider along with the beneficiary's medical needs are psychosocial determinants of health such as: i.Acute psychological symptoms (these symptoms and the need for appropriate services and supervision must have been documented by physician's orders and progress notes, or by nursing or therapy notes); ii. Age; iii. Length of stay in current placement; iv. Locationandcondition of spouse or primary caregiver; v. Proximity and availability of social support; or vi. Effectoftransferon individual, understanding that there can always be, to a greater or lesser degree, some trauma with transfer (proper and timely discharge planning helps alleviate the fear and worrv about transfer). State plan Attachment 3 .1-i: Page 1 1 Supersedes: 22-0026 *Long Tenn Care/Chronic Care Hospital **LOC= level of care 7. IEl Target Group(s). The state elects to target tl1is 1915(i) State plan HCBS benefit to a specific population based on age, disability, diagnosis, and/or eligibility group. With this election, the state will operate this program for a period of 5 years. At least 90 days prior to the end of tllis 5 year period, the state may request CMS renewal of this benefit for additional 5-year tenns in accordance with 1915(i)(7)(C) and 42 CFR 441.710(e)(2). (Specify target group(s)): The target groups will be beneficia1ies ages 3 and older with I/DD, TBI, SMI (including SPMI), SED, or severe SUD. Individuals emolled in the 1915( c) hmovations, or TBI waiver will not be included in 191 S(i) tar et ·ou s because the will have e uivalent benefits rovided throu h the 1915(c) hmovations

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State plan Attachment 3 .1-i: State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 Page 12 Supersedes: 22-0026 or TBI waiver. h1dividuals on the waitlist for the 1915(c) hlnovations or TBI waiver will be eligible to obtain 19 lS(i) se1vices if they are pait of a target group and meet the functional limitation and eligibility requirements. □ Option for Phase-in of Services and Eligibility. If the state elects to tai·get this 1915(i) State plan HCBS benefit, it may limit the emollment of individuals or the provision of se1vices to enrolled individuals in accordance with l 9 l 5(i)(7)(B)(ii) and 42 CFR 441. 745(a)(2)(ii) based upon criteria desc1ibed in a phase in plan, subject to CMS approval. At a minimum, the phase-in plan must describe: (1) the c1ite1ia used to limit enrollment or service delive1y; (2) the rationale for phasing-in se1vices and/or eligibility; ai1d (3) timelines and benchmarks to ensure that the benefit is available statewide to all eligible individuals within the initial 5-veai· approval. (Specify the phase-in plan): (By checking the following box the State assures that): 8. IE] Adjustment Authority. The state will notify CMS and the public at least 60 days before exercising the option to modify needs-based eligibility critelia in accord with 1915(i)(l)(D)(ii). 9. Reasonable Indication of Need for Services. h1 order for an individual to be detennined to need the 1915(i) State plan HCBS benefit, an individual must require: (a) the provision of at least one 1915(i) se1vice, as documented in the person-centered se1vice plan, and (b) the provision of 1915(i) se1vices at least monthly or, if the need for se1vices is less than monthly, the paiticipant requires regular monthly monitoring which must be documented in the person-centered se1vice plai1. Specify the state's policies concerning the reasonable indication of the need for 1915(i) State plan HCBS: i. Minimum number of services. The minimum number of 1915(i) State plan se1vices (one or more) that an individual must require in order to be detennined to need the 1915(i) State plan HCBS benefit is: One ii. Frequency of services. The state requires (select one): O The provision of 1915(i) services at least monthly 0 Monthly monitoring of the individual when services are furnished on a less than monthly basis If the state also requires a minimum frequency for the provision of 191 S(i) services other thai1 monthly (e.g., quaiterly), specify the frequency:

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State plan Attachment 3 .1-i: State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 Page 14 Supersedes: 22-0026 Beneficiaries may obtain 191 S(i) se1vices in the following settings: p1ivate homes, the community, group homes, integrated employment sites, or micro-enterprise. All settings where the beneficiaries obtaining 1915(i) se1vices reside and receive 1915(i) se1vices will meet and continue to meet the federal HCBS standards prior to providing se1vices and, therefore, will be in integrated settings. These HCBS mles will be applied to all individuals in residential suppo1ts and suppo1ted employment/individual placement suppo1t except where such activities or abilities are contraindicated specifically in an individual's person-centered plan and applicable due process has been executed to restrict any of the standards or lights. We have assessed the 1915(i) se1vice settings and dete1mined that the se1vices that the HCBS Final Rule will potentially impact are: • Supp01ted Employment/Individual Placement Supports • Individual and Transitional Suppo1ts (when used to suppo1t someone in a residential setting and provided by the residential provider) • Community Living and Supports (when used to support someone in a residential setting and provided by the residential provider) Please note that 1915(i) providers must comply to provide 1915(i) se1vices. Se1vices provided to individuals in private homes are assumed to meet HCBS requirements. Individuals residing in their own or family homes will be monitored to ensure that they are afforded the same rights as those in other settings. The State will monitor this through the use of the Quruterly HCBS monitoring tool. Providers must complete a self-assessment, which is reviewed by the Tailored Plan/PIHP for compliance. The Tailored Plan/PIHP may review the assessment using at least one of the following strategies to validate the self-assessment: face-to-face care management review and completion of the Care Management tool; HCBS Quarterly Monito1ing Tab, which is submitted to the Tailored Plan/PIHP; quality management/provider network team review; desk review of provider policies/procedures, Care Plans/ISPs, care management monito1ing tools and any applicable My Individual Experience (MIE) Surveys; hltense On-site Review- which may be triggered by discrepancy in policies presented, provider self-assessment, and the care management monitoring tool; and telehealth visit with two-way, real-time, interactive audio/video. DHHS also validates a sample of Tailored Plan/PIHP provider self-assessments via a desk review. An MIE Smvey is an assessment that is completed by the individual receiving HCBS. This smvey is miITored against the provider assessment; however, it is in a fo1mat that is easily understood, in person-first language, and contains graphics. The smvey asks for the provider/site where individuals receive se1vices so that the info1mation received can infonn the assessment of the provider/site. This smvey is sent to a sample of individuals in each se1vice. A series of "threshold" questions have been identified in each survey. If these questions are all answered in a mallller that is noncompliant by HCBS standards, the survey will be flagged, and the DHHS HCBS internal team and Tailored Plan/PIHP staff will be ale1ted to follow up. The DHHS HCBS internal team has provided a standardized sedes of follow-up questions to be used in the follow-up process if the smvey is flagged, and a template for repo1ting findings and follow-up actions has been provided to the Tailored Plan/PIHP staff. If the MIE results are inconsistent with the provider's self-assessment results, the provider will be required to develop a Plan of Action. An analysis of smveys and actions taken will be submitted to the DHHS HCBS internal team qua1terly.

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1-i: Page 1 5 Supersedes: 22-0026 Person-Centered Planning & Service Delivery (By checking the following boxes the state as sures that): 1. IEl There is an independent assessment of individuals detennined to be eligible for the State plan HCBS benefit. The assessment meets federal requirements at 42 CFR §441.720. 2. IEl Based on the independent assessment, there is a person-centered se1vice plan for each individual detennined to be eligible for the State plan HCBS benefit. The person-centered se1vice plan is developed using a person-centered se1vice planning process in accordance with 42 CFR §441.725(a), and the w1itten person-centered se1vice plan meets federal requirements at 42 CFR §441.725(b). 3. IEl The person-centered se1vice plan is reviewed, and revised upon reassessment of functional need as required under 42 CFR §441.720, at least eve1y 12 months, when the individual's circumstances or needs change significantly, and at the request of the individual. 4. Responsibility for Face- t o -Face Assessment of an Individual's Support Needs and Capabilities. There are educational/professional qualifications (that are reasonably related to performing assessments) of the individuals who will be responsible for conducting the independent assessment, including specific training in assessment of individuals with need for HCBS. (Specify qualifzcations): Care managers based at State-ce1tified AMH+ primaiy cai·e practices, State-ce1tified CMAs, Tailored Plans ai1d PIHPs will be responsible for completing the assessment. Care managers must meet North Cai·olina's definition of a Qualified Professional: • An individual who holds a license, provisional license, ce1tificate, registration or pemlit issued by the governing board regulating a human se1vice profession, except a registered nurse who is licensed to practice in the State ofN01th Carolina by the No1th Carolina Board of Nursing who also has four years of full-time accumulated experience in mental health, developmental disabilities and substance abuse se1vices (mh/dd/sa) with the population seived; or • A graduate of a college or university with a Master's degree in a human service field and has one year of full-time accumulated mh/dd/sa experience with the population se1ved, or a substance abuse professional who has one year of full-time accumulated supervised experience in alcoholism and dmg abuse counseling; or • A graduate of a college or university with a bachelor's degree in a human service field and has two years of full-time accumulated mh/dd/sa experience with the population se1ved, or a substance abuse professional who has two years of full-time accumulated supeivised experience in alcoholism and dmg abuse counseling; or • A graduate of a college or university with a bachelor's degree in a field other than human seivices and has four years of full-time accumulated mh/dd/sa experience with the population seived, or a substance abuse professional who has four years of full-time accmnulated supe1vised experience in alcoholism and dmg abuse counseling. The State will work with the Eastern Band of the Cherokee Indiai1s to allow CIHA to conduct the assessment for Tiibal members or individuals eligible to receive Indian Health Se1vices. The Tribal assessors will have tl1e same qualifications as other independent assessors, except that CIHA/Tribal assessors do not have to be licensed in No1th Carolina as long as they have a valid license from ai1y state. The CIHA will have oversight of the T1ibal assessors, and the State will do a sampling of the assessments to ensure that they meet the requirements. Tiibal members

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1- i: Page 16 Supersedes: 22-0026 will have a choice of who completes the assessment. Tribal assessment will only be available to Tribal members. Tribal members may choose care management and se1vices provided by Tiibal or external providers. 5. Responsibility for Development of Person- Centered Service Plan. There are qualifications (that are reasonably related to developing se1vice plans) for persons responsible for the development of the individualized, person-centered se1vice plan. (Specify qualifications): North Carolina is refening to the person-centered se1vice plan as the Care Plan for individuals with a behavioral health need and the h1dividual Suppo1t Plan (ISP) for individuals with an I/DD or TBI. Care managers based at State-certified AMH+, State-ce1tified CMAs, Tailored Plans, PIHPs and if a Tribal member, the CIRA will be responsible for Care Plan and ISP development. Care managers must meet North Carolina's definition of a Qualified Professional: • An individual who holds a license, provisional license, ce1tificate, registration or pennit issued by the governing board regulating a human se1vice profession, except a registered nurse who is licensed to practice in the State ofN01th Carolina by the No1th Carolina Board of Nursing who also has four years of full-time accumulated experience in mental health, developmental disabilities and substance abuse se1vices (mh/dd/sa) with the population served; or • A graduate of a college or university with a Masters degree in a human service field and has one year of full-time accumulated mh/dd/sa experience with the population se1ved, or a substance abuse professional who has one year of full-time accumulated supe1vised experience in alcoholism and dmg abuse counseling; or • A graduate of a college or university with a bachelor's degree in a human se1vice field and has two years of full-time accumulated mh/dd/sa experience with the population se1ved, or a substance abuse professional who has two years of full-time accumulated supervised experience in alcoholism and dmg abuse counseling; or • A graduate of a college or university with a bachelor's degree in a field other than human services and has four years of full-time mh/dd/sa experience with the population se1ved, or a substance abuse professional who has four years of full-ti.me accumulated supe1vised experience in alcoholism and dmg abuse cotmseling. 6. Supporting the Participant in Development of Person-Centered Service Plan. Suppo1ts and info1mation are made available to the pa1ticipant (and/or the additional patties specified, as approp1iate) to direct and be actively engaged in the person-centered se1vice plan development process. (Specify: (a) the supports and information made available, and (b) the participant's authority to determine who is included in the process): The Care Plan (for people with behavioral health needs) or Individual Suppo1t Plan (ISP) (for people with I/DD and TBI needs) is developed through a person-centered planning process led by the beneficiary and/or legally responsible person for the beneficia1y to the extent they desire, with support from the care manager. Person-centered planning is about supp01ting beneficiaries to realize their own vision for their lives. Person-centered planning (and as a result the person centered plan) should address whole-person care- physical and behavioral health needs as well as other needs, such as housing, food stability, etc.- to improve health/life outcomes. It is a process of building effective and collaborative paitnerships with pa1ticipants and working in paitnership with them to create a road map for the ISP for reaching the beneficiaiy' s goals. The

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1-i: Page 1 7 Supersedes: 22-0026 planning process is directed by the beneficiaiy, including who is involved with their plaiming, and identifies strengths and capabilities, desires, and suppo1t needs. 7. Informed Choice of Providers. (Describe how participants are assisted in obtaining information about and selecting from among qua lifted providers of the 1915 (i) services in the person-centered service plan): Tue Tailored Plai1s/PIHPs infonn the beneficiaiy of the right to provider choice and how to access provider directo1ies. The cai·e manager will confilm provider choice with the beneficia1y or assist them in locating a provider of 1915(i) services. Provider choice must be attested by the beneficiaiy in the Cai·e Plan or ISP. 8. Process for Making Person-Centered Se1vice Plan Subject to the Approval of the Medicaid Agency. (Describe the process by which the person-centered service plan is made subject to the approval of the Medicaid agency): Tue h1dividual Suppo1t Plan (ISP) or Care Plan is submitted by the care manager to the Tailored Plai1 or PIHP in which the beneficiaiy is emolled. The ISP or Cai·e Plan is reviewed and approved by the beneficia1y's Tailored Plan/PIHP. The State will work with the External Quality Review (EQR) to sainple plans to ensure that they meet the requirements for person-centered plai1s. 9. Maintenance of Person-Centered Service Plan Forms. Wtitten copies or electronic facsimiles of se1vice plans are maintained for a minimum petiod of 3 yeai·s as required by 45 CFR §74.53. Se1vice plans ai·e maintained by the following (check each that applies): □ Medicaid a enc □ !El Case mana er □ Other (specify): Services 1. State plan HCBS. (Complete the following table for each service. Copy table as needed): Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Se1vice Title: I Supp01ted Employment/Individual Placement Supp01ts Se1vice Definition (Scope): The intent of Suppo1ted Employment/Individual Placement Suppo1ts is to assist individuals in developing/regaining skills to seek, obtain, and maintain competitive employment, or develop and operate a micro-enterprise. The employment positions ai·e found based on individual preferences, strengths, and expe1iences. Suppo1ted Employment includes Individual Placement Suppo1ts which is an evidenced based practice of Suppo1ted Employment. Please note that any exclusions for Suppo1ted Employment would apply to Individual Placement Suppo1ts. Beneficiai·ies with a youth employment ce1tificate will be evaluated on a case-by-case basis. The se1vice includes transportation to and from the se1vice and/or the job site only if there is no other viable and more cost-effective alternative available to the beneficiaiy.

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State plan Attachment 3 .1-i: State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 Page 19 Supersedes: 22-0026 Exclusions: federal financial paiticipation (FFP) cannot be claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following: 1. incentive payments made to an employer to encourage or subsidize the employer's pa1ticipation in a supported employment program, 2. payments that ai·e passed through to users of supported employment programs, or 3. payments for training that are not directly related to a beneficiaiy's suppo1ted employment program. The following types of situations are indicative of a provider subsidizing its paiticipation in suppo1ted employment: 1. The job/position would not exist if the provider agency was not being paid to provide the service. 2. Tue job/position would end if the individual chose a different provider agency to provide service. 3. The hours of employment have a one-to-one conelation with the number of hours of se1vice that ai·e authorized. For individuals who ai·e eligible for educational services Ullder the Individuals with Disability Education Act, Suppo1ted Employment does not include transportation to or from school settings. This includes transpo1tation to or from the individual's home, the provider home where the individual may be receiving services before or after school, or any other community location where the individual may be receiving se1vices before or after school. Suppo1ted Employment services occur in integrated environments with nondisabled individuals or in a business owned by the beneficiaiy. Supported Employment se1vices do not occur in licensed community day programs. While it is not prohibited to both employ an individual and provide se1vices to that same individual, the use of Medicaid funds to pay for Suppo1ted Employment se1vices to providers that are subsidizing their pa1ticipation in providing this service is prohibited. Se1vices may not occur in segregated settings or sheltered workshops. The following activities ai·e not covered under Suppo1ted Employment/Individual Placement Suppo1ts: a) Services provided to teach academic subjects or as a substitute for educational personnel, including a teacher, teacher's aide, or academic tutor; b) Pre-vocational classes; c) Suppo1ts and/or se1vices to help individuals with volllllteering; d) Set-aside jobs for people with disabilities, such as enclaves; e) Transitional employment; t) Group employment searches or classes; g) Habilitative se1vices for the individual to acquire, retain, and improve the self-help, socialization, and adaptive skills necessaiy to reside successfully in community settings; h) Non-employment-related transpo1tation for the individual or family; i) Any se1vices provided to family, friends, or natural suppo1ts of the individual receiving Suppo1ted Employment/Individual Placement Supports to address problems not directly related to the individual's issues and not listed on the ISP, Care Plan, and/or Employment Plai1; j) Clinical and administrative supe1vision of staff; k) Time spent in meetings where the eligible individual is not present; and 1) For the IPS model for MH ai1d SUD, group employment/work crews. Additionally, if an eligible individual is receiving se1vices from both DHB and the Division of Vocational Rehabilitation Services (DVR), Medicaid funds will only reimburse for se1vices not covered by DVR or in an employment milestone funded by DVR. IEl Medically needy (specify limits):

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1-i: Page 21 Supersedes: 22-0026 Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19- B that the state plans to cover): Se1vice Title: I Community Living and Supports Service Definition (Scope): This is an individualized se1vice that enables the beneficiary to live successfully in his/her own home or the home of his/her family or natural supports and be an active member of his/her community. A paraprofessional assists the person to learn new skills and/or supports the person in activities that are individualized and aligned with the person's preferences. The intended outcome of the se1vice is to increase or maintain the person's life skills or provide the supe1vision needed to empower the person to live in the home of his/her family or natural suppo1ts, maximize his or her self-suffidency, increase self- determination and enhance the person's opportunity to have full membership in his/her community. TI1is service enables the person to learn new skills, practice and/or improve existing skills. Areas of skill acquisition are interpersonal, independent living, community living, self-care, and self-detennination. This service provides supervision and assistance for the person to complete an activity to his/her level of independence. Areas of suppo1t consist of assistance in monitoring a health condition, nutrition or physical condition, incidental supe1vision, daily living skills, community pa1ticipation, and interpersonal skills. Additional needs-based criteria for receiving the se1vice, if aoolicable (svecifv): At least one functional deficit who can benefit from skill acquisition in one area noted above. Specify limits (if any) on the amount, duration, or scope of this se1vice. Per 42 CFR Section 440.240, services available to any catego1ically needy recipient cannot be less in amount, duration and scope than those se1vices available to a medically needy recipient, and se1vices must be equal for any individual within a group. States must also separately address standard state plan se1vice questions related to sufficiency of se1vices. (Choose each that avvlies): IE) Categodcallv needy (specifv limits): a. This service may be provided to Adult @ 28 hours/week; Child @ 15 hours/week (when in school) or 28 hours/week (when not in school) b. For individuals who are eligible for educational se1vices under the Individuals with Disability Education Act, Co1mnunity Living and Suppo1ts does not include transportation to/from school settings. This includes transpo1tation to/from beneficia1y's home, provider home where the beneficiruy is receiving se1vices before/after school or any community location where the beneficia1y may be receiving se1vices before or after school. C. This se1vice may not be provided dilling the same time as ru1y other direct support Medicaid se1vice. IE) Medically needy (svecifv limits): Same as categorically needy. Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type License Ce1tification Other Standard (Specify): (Specify): (Specify): (Specify): Provider NIA NIA • Meet provider ffilalification policies,

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 Agencies, which are defmed as providers who have a contract with the Tailored Plan/PIHP, are accredited within a year of starting se1vices, and are enrolled with NC Medicaid. §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1-i: Page 22 Supersedes: 22-0026 procedures, and standards established by DHB, and be enrolled in NC Medicaid; • Fulfill the requirements of 1 0A NCAC 27G; • Comply with all applicable federal and State requirements, including DHHS statutes, rnles, policies, communication bulletins, and other published instrnctions; • Obtain national accreditation within one year of enrollment (COA, CARF, CQL, or Joint Commission). • Federally recognized tribal and Indian Health Se1vice providers, such as EBCI Vocational Opportunities Center, may be exempt from one or more of these items in accordance with Federal law and regulations and have substantial equivalency Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type Entity Responsible for Verification Frequency of Verification (Specify): (Specifv): (Specify): Provider NC Medicaid or Vendor Upon enrollment and Agencies eve1y three years Service Delivery Method. (Check each that avvlies): □ I Pa1ticipant-directed I IEl I Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19- B that the state plans to cover): Se1vice Title: I Individual and Transitional Supports Se1vice Definition (Scope): This se1vice provides support in acquiiing, retaining, and improving self-help, socialization, and adaptive skills necessary to be successful in employment, education, community life, maintaining housiI1g, and residing successfully in the community. A paraprofessional assists the person in learning new skills and/or suppo1ts the person in activities that are individualized and aligned with the person's preferences. The intended outcome of the se1vice is to increase or maintain the person's life skills to empower the person, increase self-detennination, and enhance the person's oppo1tunity to have full membership in his/her community. Areas of suppo1t consist of assistance in monitoring a health condition, nutrition, or physical condition; incidental supervision; daily

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1-i: Page 23 Supersedes: 22-0026 living skills; community paiticipation; interpersonal skills; and suppo1t to maintain abstinence through the development of relapse prevention skills. Additional needs-based criteria for receiving the se1vice, if applicable (specifv): At least one deficit in an ADL or instrumental activity of daily living (IADL). Specify limits (if any) on the amount, duration, or scope of this se1vice. Per 42 CFR Section 440.240, services available to any categorically needy recipient caimot be less in amount, duration and scope thai1 those se1vices available to a medically needy recipient, and se1vices must be equal for any individual within a group. States must also sepai·ately address standard state plan se1vice questions related to sufficiency of se1vices. (Choose each that applies): IE) Categodcallv needy (specifv limits): a. This se1vice may not be provided in a group. Housekeeping, homemaking, or basic services solely for the convenience of the caregiver of the beneficiaiy receiving the se1vices are not covered. This se1vice may not be provided if the se1vice is othe1wise available lmder a program funded m1der the Rehabilitation Act of 1973, P.L. 94-142, or m1der the h1dividuals with Disabilities Education Act, 20 U.S.C. 1401 et seq. b. For individuals who are eligible for educational se1vices under the hldividuals with Disability Education Act, hldividual and Transitional Suppo1ts does not include transpo1tation to/from school settings. This includes transpo1tation to/from the beneficiaiy's home, the provider home where the beneficiaiy is receiving se1vices before/after school, or any community location where the beneficiaiy may be receiving se1vices before or after school. c. This se1vice may not be provided dming the saine time as any other direct support Medicaid se1vice. d. This service may not be provided dming the same authorization period as Asse1tive Community Treatment or Com1mmity Suppo1t Team. e. This se1vice may not be provided to children ages 16 to 21 who reside in a Medicaid-funded group residential treatment facility. f. This se1vice may not be provided by fainily members. g. This se1vice may be provided up to 60 hours per month for rehabilitation. IE) Medically needy (specifv limits): Same as categorically needy. Provider Qualifications (For each tvpe of provider. Copv rows as needed): Provider Type License Ce1tification Other Standard (Specify): (Specify): (Specify): (Specify): Provider NIA NIA • Meet provider qualification policies, Agencies, procedures, and stai1dards which are established by DHB, and be enrolled defined as in NC Medicaid; providers who • Fulfill the requirements of 1 0A have a contract NCAC 27G; with the Tailored • Comply with all applicable federal

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 Plan/PIHP, are accredited within a year of staiting se1vices, and are enrolled with NC Medicaid. §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1-i: Page 24 Supersedes: 22-0026 and State requirements, including DHHS statutes, mles, policies, communication bulletins, and other published instmctions; • Obtain national accreditation within one year of enrollment (COA, CARF, CQL, or Joint Commission). • Federally recognized t1ibal and Indian Health Se1vice providers, such as EBCI Vocational Opportunities Center, may be exempt from one or more of these items in accordance with Federal law and regulations and have substantial equivalency Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type Entity Responsible for Verification Frequency ofVe1ification (Specify): (Specifv): (Specify): Provider NC Medicaid or Vendor Upon enrolhnent and Agencies eve1y three years Service Delivery Method. (Check each that applies): D I Pa1ticipant-directed I IEl I Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Se1vice Title: I Respite Se1vice Definition (Scope): Respite services are to provide periodic or scheduled suppolt and relief to the primary caregiver(s) from the responsibility and stress of caring for the individual. Respite may also be used to provide tempora1y relief to prima1y caregiver( s) of individuals who reside in Licensed and Unlicensed AFLs, as well as Therapeutic Foster Car·e. This se1vice enables the primary caregiver to meet or participate in planned or emergency events and to have planned time for himself/herself and/or family members. This se1vice also enables the individual to receive periodic support arid relief from the primary caregiver(s) of his/her choice. Respite may be utilized during school hours for sickness or injmy. Respite may include in-home and out-of-home se1vices, inclusive of overnight, weekend car·e, or emergency care (family-emergency-based, not to include an out-of-home crisis). The primary caregiver(s) is the person principally responsible for the car·e and supe1vision of the beneficia1y arid must maintain his/her p1ima1y residence at the same address as the beneficiary.

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State plan Attachment 3 .1-i: State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 Page 25 Supersedes: 22-0026 Additional needs-based criteria for receiving the service, if applicable (specify): To be eligible for this se1vice, an individual must: • Require assistance with at least one of the following areas of major life activity, as appropriate to the person's age: receptive and expressive language, learning, self-care, mobility, self-direction, or capacity for independent living; or • Not have the ability to care for themselves in the absence of a primary caregiver and have needs that exceed that of a child without behavioral health concerns/developmental disabilities that could have care provided by a traditional babysitter or day care. Specify limits (if any) on the amount, duration, or scope of this se1vice. Per 42 CFR Section 440.240, se1vices available to any categorically needy recipient callllot be less in amount, duration and scope than those se1vices available to a medically needy recipient, and se1vices must be equal for any individual within a group. States must also separately address standard state plan se1vice questions related to sufficiency of se1vices. (Choose each that applies): 0 Catego1ically needy (specify limits): a. This se1vice may not be used as a regularly scheduled daily se1vice in individual supp01t. b. This service is not available to beneficiruies who reside in licensed facilities that are licensed as 5600B or 5600C. Staff sleep time is not reimbursable. c. Respite services are only provided for the individual; other family members, such as siblings of the individual, may not receive cru·e from the provider while Respite cru·e is being provided/billed for the individual. d. Respite care is not provided by any person who resides in the individual's prima1y place of residence. e. FFP will not be claimed for the cost of room and board except when provided as pa1t of Respite care furnished in an institution. f. For individuals who ru·e eligible for educational se1vices Ullder the Individuals with Disability Education Act, Respite does not include transpo1tation to/from school settings. This includes transpo1tation to/from the beneficiary's home, the provider home where the beneficia1y is receiving se1vices before/after school, or any community location where the benefida1y may be receiving services before or after school. g. Respite may not be used for beneficiru·ies who are living alone or with a roommate. h. There is a limit of 300 hours per yeru· of Respite per beneficiruy. i. Respite is a short-tenn se1vice. j. Providers of residential se1vices (AFLs and Therapeutic Foster Cru·e) may not be paid for the same times that an individual is receiving Respite care. k. Members emolled in the CAP/C or CAP/DA waiver ru·e not eligible for Respite se1vices in the 1915(i). 0 Medically needy (specify limits): Same as categorically needy. Provider Qualifications (For each type of provider. Copy rows as needed):

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State plan Attachment 3 .1-i: State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 Page 27 Supersedes: 22-0026 The purpose of Community Transition is to provide initial setup to facilitate the individual's transition from a State Developmental Center (ICF-IID), community ICF-IID, nursing facility,, or another provider-operated/controlled settings (adult care home, psychiatric residential treatment facility, foster home, AFL (Alternative Family Living), group home) to a living anangement where the individual is directly responsible for his or her own living expenses. The state cannot claim FFP for these se1vices until the individual is determined eligible for and em-olled into the 1915(i) State Plan benefit. These are one-time, non-reoccuning expenses. hldividuals transitioning from an institutional setting may receive transitional assistance to any home and conununity-based setting that meets the HCBS settings requirements. This se1vice may be provided only in a p1ivate home or apartment with a lease in the individual's/legal guardian's/representative's name or a home owned by the individual. Covered transition se1vices are: a. Security deposits that are required to obtain a lease on an apartment or home; b. Essential furnishings, such as fiuniture, window cove1ings, food preparation items, bed/bath linens; c. Moving expenses required to occupy and use a community domicile; d. Setup fees or deposits for utility or service access, such as telephone, electricity, heating and water; e. Se1vices necessaiy for the beneficia1y's health and safety, such as pest eradication and one-time cleaning p1ior to occupancy. Additional needs-based cliteria for receiving the se1vice, if applicable (specify): hldividuals who are moving from a living arrangement that they do not control into their own home in the commmiity and need initial setup expenses/items. Specify limits (if any) on the amount, duration, or scope of this se1vice. Per 42 CFR Section 440.240, se1vices available to any categ01ically needy recipient cannot be less in amomlt, duration and scope than those se1vices available to a medically needy recipient, and se1vices must be equal for any individual within a group. States must also separately address standard state plan se1vice questions related to sufficiency of se1vices. (Choose each that applies): 0 Categolically needy (specify limits): a. Community Transition does not cover monthly rental or mortgage expenses; food expenses; regular utility charges; or household appliances or diversional/recreational items such as televisions, VCR players and components, and DVD players and components. Se1vice and maintenance contracts and extended warranties are not covered. b. Co1mnunity Transition has a liniit of $5,000 per individual dming the five-year pe1iod. c. Commmiity Transition is available tlu·ee months in advance of the individual's move. d. In situations where an individual lives with a roommate, Co1mmuiity Transition cannot duplicate items that are currently available. e. Community Transition includes the acnial cost of services and does not cover provider overhead charges. f. Community Transition expenses are funiished only to the extent that the beneficiaiy is unable to meet such expenses or when the support cal1llot be obtained from other sources. The Comm1niity Transition Checklist is completed to document the items requested under this definition. The checklist is submitted to the Tailored Plan/PIHP by the agency tliat is

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 providing the se1vices. 2· Food expenses are prohibited. State plan Attachment 3 .1-i: Page 28 Supersedes: 22-0026 h. Members ages 21 through 64 transitioning from an IMD are not eligible for Community Transition services in the 1915(i). i. Members enrolled in the CAP/C or CAP/DA wavier are not eligible for Community Transition se1vices in the 1915(i). 0 Medically needy (spec.ify limits): Same as categorically needy. Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type License Ce1tification Other Standard (Specify): (Specify): (Specify): (Specify): Specialized NIA NIA Meets applicable State and local Vendors/Suppliers regulations for the type of se1vice that the provider/supplier is providing as approved by Tailored Plan/PIHP Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type Entity Responsible for Ve1ification Frequency of Verification (Specify): (Specify): (Specify): Vendors/Suppliers Tailored Plan/PIHP !At the time of first use Service Delivery Method. (Check each that applies): D I Paiticipant-directed I 0 I Provider-managed 2. IEl Policies Concerning Payment for State plan HCBS Furnished by Relatives, Legally Responsible Individuals, and Legal Guardians. (By checking this box the state assures that): There are policies pe1taining to payment the state makes to qualified persons furnishing State plan HCBS, who are relatives of the individual. There are additional policies and controls if the state makes payment to qualified legally responsible individuals or legal guardians who provide State Plan HCBS. (Specify (a) who may be paid to provide State plan HCBS; (b) the specific State plan HCBS that can be provided; (c) how the state ensures that the provision of services by such persons is in the best interest of the individual; ( d) the state '.s- strategies for ongoing monitoring of sen1ices provided by such persons; (e) the controls to ensure that payments are made only for services rendered; and (I) if legally responsible individuals may provide personal care or similar sen1ices, the policies to determine and ensure that the services are extraordinary (over and above that which 1-vould ordinarily be provided by a legally responsible individual): Community Living and Suppo1t seivices may be provided to an adult beneficia1y by a parent or relative who resides with the beneficia1y.

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1-i: Page 30 Supersedes: 22-0026 Participant-Direction of Services Definition: Participant-direction means self-direction of services per §1915(i)(l)(G)(iii). 1. Election of Participant- Direction. (Select one): 0 The state does not offer oooortunitv for oarticioant-direction of State olan HCBS. 0 Eve1y participant in State plan HCBS (or the participant's representative) is afforded the opportunity to elect to direct se1vices. Alternate se1vice delivery methods are available for participants who decide not to direct their se1vices. 0 Paiticipants in State plan HCBS (or the pa1ticipant's representative) are afforded the opportunity to direct some or all of their se1vices, subject to ciiteiia specified by the state. (Specify criteria): 2. Description of Participant- Direction. (Provide an overview of the opportunities for participant direction under the State plan HCBS, including: (a) the nature of the opportunities afforded,· (b) how participants may take advantage of these opportunities; (c) the entities that support individuals who direct their services and the supports that they provide; and, (d) other relevant information about the approach to participant-direction): 3. Limited Implementation of Participant- Direction. (Participant direction is a mode of service delivery, not a Medicaid service, and so is not subject to statewideness requirements. Select one): 0 Pa1ticipant direction is available in all geographic ai·eas in which State plan HCBS are available. 0 Paiticipant-direction is available only to individuals who reside in the following geographic areas or political subdivisions of the state. Individuals who reside in these ai·eas may elect self-directed se1vice delive1y options offered by the state, or may choose instead to receive compai·able se1vices through the benefit's standard se1vice delive1y methods that are in effect in all geographic areas in which State plan HCBS ai·e available. (Specify the areas of the state affected by this option): 4. Participant-Directed Services. (Indicate the State plan HCBS that may be participant-directed and the authority ofered for each. Add lines as required): Participant- Directed Service 5. Financial Management. (Select one) : Employer Authority □ □ Budget Authority □ □ 0 Financial Management is not furnished. Standard Medicaid payment mechanisms are used. i Finai1cial Management is furnished as a Medicaid administrative activity necessaiy for administration of the Medicaid State plan.

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State: No1th Carolina TN: 24-0018 Effective: 07/01/2024 §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1-i: Page 31 Supersedes: 22-0026 6. □ Patiicipant- Directed Person-Centered Service Plan. (By checking this box the state assures that): Based on the independent assessment required under 42 CFR §441. 720, the individualized person-centered se1vice plan is developed jointly with the individual, meets federal requirements at 42 CFR §441. 725, and: • Specifies the State plan HCBS that the individual will be responsible for directing; • Identifies the methods by which the individual will plan, direct or control se1vices, including whether the individual will exercise authoiity over the employment of se1vice providers and/or authority over expenditures from the individualized budget; • Includes appropriate Iisk management techniques that explicitly recognize the roles and sharing of responsibilities in obtaining services in a self-directed mam1er and assures the appropriateness of this plan based upon the resources and supp01t needs of the individual; • Desc1ibes the process for facilitating volunta1y and involunta1y transition from self-direction including any circumstances under which transition out of self-direction is involuntruy. There must be state procedures to ensure the continuity of se1vices dming the transition from self-direction to other se1vice delive1y methods; and • Specifies the financial management suppo1ts to be provided. 7. Voluntary and Involuntary Termination of Participant-Direction. (Describe how the state facilitates an individual '.s transition from participant-direction, and specify any circumstances when transition is involuntary): NIA 8. Opportunities for Participant-Direction a. Participant- Employer Authority (individual can select, manage, and dismiss State plan HCBS providers). (Select one): 0 The state does not offer oppo1tllllity for pa1ticipant-employer authority. 0 Pa1ticipants may elect participant-employer Authority (Check each that applies): □ Participant/Co-Employer. The participar1t (or the participant's representative) functions as the co-employer (managing employer) of workers who provide waiver se1vices. An agency is the co1mnon law employer of pa1ticipant-selected/recrnited staff and pe1fo1ms necessa1y payroll and human resources functions. Suppo1ts ar·e available to assist the participant in conducting employer-related functions. □ Participant/Common Law Employer. The participant (or the pa1ticipant's representative) is the co1mnon law employer of workers who provide waiver se1vices. An IRS-approved Fiscal/Employer Agent functions as the participant's agent in performing payroll and other employer responsibilities that are required by federal and state law. Suppo1ts are available to assist the pa1ticipant in conducting employer-related functions. b. Participant- Budget Authority (individual directs a budget that does not result in payment for medical assistance to the individual). (Select one): 0 The state does not offer opportunity for participants to direct a budget. 0 Pa1ticipar1ts may elect Pa1ticipar1t-Budget Authority.

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State: North Carolina TN: 24-0018 Effective: 07/01/2024 Quality Measures §1915(i) State plan HCBS Approved: 06/21/2024 State plan Attachment 3 .1-i: Page 33 Supersedes: 22-0026 Quality Improvement Strategy (Describe the state's quality improvement strategy. For each requirement, and lettered sub-requirement, complete the table below): 1. Service plans a) address assessed needs of 1915(i) participants; b) are updated annually; and (c document choice of services and providers. 2. Eligibility Requirements: (a) an evaluation for 1915(i) State plan HCBS eligibility is provided to all applicants for whom there is reasonable indication that 1915(i) services may be needed in the future; (b) the processes and instruments described in the approved state plan for determining 1915(i) eligibility are applied appropriately; and (c) the 1915(i) benefit eligibility of enrolled individuals is reevaluated at least annually or if more frequent, as specified in the approved state plan for 1915(i) HCBS. 3. Providers meet required qualifications. 4. Settings meet the home and community-based setting requirements as specified in this SP A and in accordance with 42 CFR 441.710(a)(l) and (2). 5. The SMA retains authority and responsibility for program operations and oversight. 6. The SMA maintains financial accountability through payment of claims for services that are authorized and furnished to 1915(i) participants by qualified providers. 7. The state identifies, addresses, and seeks to prevent incidents of abuse, neglect, and exploitation, including the use of restraints. (Table repeats for each measure for each requirement and lettered sub-requirement above.) Requirement la. Service plans address assessed needs of 1915(i) puticipants. Discovery Discovery Percentage of beneficiaries repo1ting that their Care Plan/ISP has the services that Evidence they need (Peifonnance N=Care Plans/ISPs where beneficiaties indicate their Care Plan/ISP addresses their Measure) needs D=Total number of Care Plans/ISPs for beneficiaties using 1915(i) se1vices Discovery ISP review 1000/o Activity (Source of Data & sample size) Monitoring Tailored Plan or PIHP Responsibilities (Agency or entity that conducts discovery activities) Frequency Annually

(nc-09-017)(approval-document)North Carolina Medicaid SPA NC-09-017: Approval Document (approved February 4, 2010, effective July 1, 2009)#

(nc-09-017)(approval-document)North Carolina Medicaid SPA NC-09-017: Approval Document (approved February 4, 2010, effective July 1, 2009)#

(nc-09-017)(attachment)North Carolina Medicaid SPA NC-09-017: Attachment (approved February 4, 2010, effective July 1, 2009)#

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(nc-09-017)(form-cms-179)North Carolina Medicaid SPA NC-09-017: Form CMS-179 (approved February 4, 2010, effective July 1, 2009)#

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(nc-11-020)(approval-document)North Carolina Medicaid SPA NC-11-020: Approval Document (approved October 20, 2011, effective November 1, 2011)#

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(nc-13-004)(approval-document)North Carolina Medicaid SPA NC-13-004: Approval Document (approved June 7, 2013, effective November 1, 2013)#

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(nc-13-004)(attachment)North Carolina Medicaid SPA NC-13-004: Attachment (approved June 7, 2013, effective November 1, 2013)#

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(nc-13-004)(form-cms-179)North Carolina Medicaid SPA NC-13-004: Form CMS-179 (approved June 7, 2013, effective November 1, 2013)#

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(nc-13-013)(approval-document)North Carolina Medicaid SPA NC-13-013: Approval Document (approved December 11, 2013, effective August 1, 2013)#

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(nc-13-0014-mm1)(approval-document)North Carolina Medicaid SPA NC-13-0014-MM1: Approval Document (approved December 10, 2013, effective January 1, 2014)#

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