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

Region VIII

August 21, 2013

Julie Schwab, Medicaid Director Medical Services Division North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250

RE: North Dakota #13-011

Dear Ms. Schwab:

We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number (TN) 13-011. This SPA implements Concurrent Hospice Care for Children in accordance with Section 2302 of the Affordable Care Act.

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

If you have any questions concerning this amendment, please contact Ann Clemens at (303) 844-2125.

Sincerely,

/s/

Richard C. Allen

Associate Regional Administrator

Division for Medicaid and Children’s Health Operations

CC: Maggie Anderson, ND

Kathy Rodin, ND

Revision: HCFA-PM- 86- 20 ( BERC) ATTACHMENT 3. 1- A March 1987 Page 7 State: North Dakota OMB No: 0938- 0193 AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 15. a. Intermediate care facility services (other than such services in an institution for mental diseases) for persons determined, in accordance with section 1902( a)( 31)( a) of the Act, to be in need of such care. Provided: No Limitations With Limitations* Not Provided b. Including such services in a public institution ( of distinct part thereof) for the mentally retarded or persons with related conditions. Provided: No Limitations With Limitations* Not Provided 16. Inpatient psychiatric facility services for individuals under 22 years of age. Provided: No Limitations With Limitations* Not Provided 16. a. Limitations for Psychiatric Residential Treatment Facilities. Provided: No Limitations With Limitations* Not Provided 17. Nurse- midwife services. Provided: No Limitations With Limitations* Not Provided 18. Hospice care ( in accordance with section 1905( 0) of the Act.) Provided: No Limitations With Limitations* Not Provided Provided in accordance with section 2302 of the Affordable Care Act Description provided on attachment. TN No. 13- 011 Approval Date: g a 13 Effective Date: July 1, 2013 Supersedes TN No: 06- 006 HCFA IC: 0069P/0002P

Revision: HCFA-PM- 86- 20 ( BERC) ATTACHMENT 3. 1- B March 1987 Page 6 State: North Dakota OMB No: 0938- 0193 AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY c. Intermediate care facility services. Provided: No Limitations With Limitations* 15. a. Intermediate care facility services (other than such services in an institution for mental diseases) for persons determined in accordance with section 1902( a)( 31)( a) of the Act, to be in need of such care. Provided: No Limitations With Limitations* b. Including such services in a public institution ( or distinct part thereof) for the mentally retarded or persons with related conditions. Provided: No Limitations With Limitations* 16. Inpatient psychiatric facility services for individuals under 22 years of age. Provided: No Limitations With Limitations* 16. a. Limitations for Psychiatric Residential Treatment Facilities. Provided No Limitations With Limitations* 17. Nurse- midwife services. Provided: No Limitations With Limitations* 18. Hospice care ( in accordance with section 1905(0) of the Act.) Provided: No Limitations With Limitations* Provided in accordance with section 2302 of the Affordable Care Act Description provided on attachment. TN No. 13- 011 Approval Date: ' 1, 11113 Effective Date: July 1, 2013 Supersedes TN No: 06- 006 HCFA IC: 0140P/ 0102A

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938- 0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 13 - 011 North Dakota FOR: HEALTH CARE FINANCING ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAID TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES July 1, 2013 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: 7. FEDERAL BUDGET IMPACT: a. FFY 2013 S 3,500.00 Section 2302 of the ACA b. FFY 2014 39,600.00 8, PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable): Attachment 3. 1- B, page 6 Attachment 3. 1- B, page 6 Attachment 3. 1- A, page 7 Attachment 3. 1- A, page 7 10, SUBJECT OF AMENDMENT: Amends the State Plan in accordance with Section 2302 of the Affordable Care Act- Concurrent Hospice Care for Children in Medicaid 11, GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED Maggie D. Anderson, Director, NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Department of Human Services 12, SIGNA U OF STATE AGNCY- FFIC L: 16. RETURN TO: eNtic 1 Maggie D. Anderson, Director 13. TYPED N ME: ' Maggie D. Anderson ND Department of Human Services 14, TITLE: 600 East Boulevard Avenue Dept 325 Executive Director, ND Dept. of Human Services Bismarck ND 58505-0250 15. DATE SUBMITTED: August 19, 2013 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE.APPROVED: r3 PLAN APPROVED— ONE COPY ATTACHED 19, EFFECTIVE DATE OF APPROVED MAT RIAL: 20. SIGNA OF GIO AL OFFICIAL: w 13 21. TYPED NAME: 22.' ISITLE: 23. REMARKS: FORM HCFA- 179 ( 07- 92)

CMS, Denver, Region VIII Page 1 of 1 December 17, 2013 _____________________________________________________________________________

Table of Contents

State/Territory Name: North Dakota State Plan Amendment (SPA) #: ND-13-0017-MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Superseding Pages Notice 4) Approved SPA Pages

_____________________________________________________________________________

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services mom 1600 Broadway, Suite 700 Denver, CO 80202-4967 cl FNMRS 10K MEDICARE M[ JXAWSIWO Region VIII December 10, 2013 Julie Schwab, Medicaid Director Medical Services Division North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505- 0250 RE: North Dakota# 13- 017- MM1 Dear Ms. Schwab: Enclosed is an approved copy ofNorth Dakota' s state plan amendment ( SPA) 13- 017-MM1, which was submitted to CMS on August 28, 2013. SPA 13- 0017-MM1 incorporates the MAGI- based mandatory and optional eligibility groups' requirements into North Dakota' s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is January 1, 2014. We are sending a copy of the following state plan pages and attachments to be incorporated within a separate section at the end of North Dakota' s approved state plan: S14, S25, S28, S30, S32, S33, S50, S51, S52, S53, S54, S55, S57, S59 In addition we will send a summary of the state plan pages which are superseded by SPA 13- 0017-MM1, which should also be incorporated into a separate section in the front of the state plan. Superseding pages of state plan material, SPA 13- 0017- MM1 CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this amendment, please contact Ann Clemens at ( 303) 844- 2125. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health Operations CC: Maggie Anderson, ND Kathy Rodin, ND

74[}. 0562. R00.00 - Jan O|, 20| 4 Page | o[ 2 C,`,0S 1 mtam/ cenbvr' oumv: North 0nkoru Transmittal Number: Please enterthe Transmittal Number( TN) in theformatST-YY-0000 where ST= the state abbreviation, YY= ti;elasttwo digits of the submission year, and omm~ o/» ur digit number with leading zeros. The dashes must also oeentered. NO' 13' OO17 Proposed Effective Date 01/ 01/ 2014 rnm/ du/ rrrr) Federal Statute/ Regulation Citation Federal Budget Impact Federal Fiscal Yeu, Amount First Vour 2014 1SO2G8375. 00 8«,^ ndVwur 2015 213888500. 00 Subject oyAmendment ACA Medicaid 6| igi6| ity SPA- Bucket \ ' MAGI- Based Eligibility Groups Governor' s Office Review Governor' s office reported ovcomment Comments v[ Governor' s v[ Dow received Describe: No reply received within 45 days ofsubmittal Other, as epaodlmt Describe: Authority m prepare and submit Medicaid State Plans is provided mthe Single State Medicaid Agency. Signature o[ State Agency Offidn] Submitted By: Maggie Anderson Last Revision Date: Dec 0, 2O13 Submit Date: Dec 3, 2Ol3 TN: wo' 13-0017' mM1 Approval Date: 12110/ 13 Effective Date: o1m1/ 2u14 North Dakota Summary, page 1 http:// 157. 199. 113. 99/ MMDL/faces/ protected/ mac/ cOl/ print/PrintSelectorjsp 12/ 11/ 2013

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13- 0017 North Dakota Pages or sections of pages being superseded by S14, 525, 528, S30, 551, 552, 553, 554, and 555, and related pages or sections of pages being deleted as obsolete State Plan Section Complete Pages Removed Partial Pages Removed Section 2 Page 11, 2. 1 ( b) ( 3) Page 1 Page 2, A. 2. b Page 3 Page 2, A. 2 . c Page 3a Page 2a, A. 3 Page 4 Page 5, A. 10 Page 4a Page 9c, B. 1 for Attachment 2. 2- A Page 12 caretaker relatives & Page 13 pregnant women Page 13a Page 20, B. 14 Page 14 Page 14a Page 21 Page 23 Supplement 1 to Attachment 2. 2- A Page 1 Page 3b Page 1, A. 2. a( i) and Page lla iii) Page 19 Page 6 related to AFDC Page 19a recipients, pregnant Attachment 2. 6- A Page 19b women, infants, and Page 21 children Page 7, l. a ( 1) and ( 2) Page 12, C. 1. e ( 2) Page 1B, C. 5. e Page 25, ll. a( 3) Supplement 1 to Attachment 2. 6- A Pages 1- 4 Supplement 2 to Attachment 2. 6- A Pages 1- 5 1 TN: ND- 13- 0017- MM1 Approval Date: 12110/ 13 Effective Date: 01/ 01/ 2014 North Dakota Superseding Pages, page 1

Pages 1- 6 related to AFDC recipients, Supplement 8a to Attachment 2. 6- A pregnant women, infants, and children Pages 1, la, 2, 2A, Supplement 8b to Attachment 2. 6- A 3, 4, and 8 related to families and children Supplement 12a to Attachment 2. 6- A Pages 1- 8 Supplement 14 to Attachment 2. 6- A Page 1 2 TN: ND- 13- 0017- MM1 Approval Date: 12/ 10/ 13 Effective Date: 01/ 01/ 2014 North Dakota Superseding Pages, page 2

Medicaid Eligibility ONI B Control NUrnhCr 0938- 1148 O'VIB Expiration date: 10/ 31/' 01, 4 AFDC Income Standards IS14, Enter the AFDC Standards below. All states must enter: MAGI- equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC, Payment Standard in Effect As of'July 16. 1996 Entry of other standards is optional. M,AGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 Income Standard Entry- Dollar Amount Automatic Increase Option S13a The standard is as follows: Statewide standard C Standard varies by region Standard varies by living arrangement C' Standard varies in some other way Enter the standard by living arrangement Remove Living Arrangement Name of living arrangement Description 0 caretaker I lousehold with no caretaker Additional incremental mnount Household size Standard ... ..... Yes C No 1 106 x Increment amount nt 2 189 3 274 4 331) x 5 393 x 6 433 x 7 473 x 8 513 Tk,-N-Q1 Effective Date: 01/ 01/ 2014 Pate I ot' 7

Medicaid Eligibility Name of living arrangement Description caretaker- 1 i Household with I caretaker I i0LISChOI( I Size Standard Additional incremental amount Yes C No 1 227 Increment amount [ 47' 2 316 415 x 4 507 x 5 577 x 6 631) x 7 686 x 8 733 x 780 x Remove Living Arrangement Name of living arrangement Description N, ith 2 caretakers 2 caretakers Household Household size Standard I 2 345 3 427 4 521 5 594 TN: ND- 13- 0017- MM1 Approval Date: 12/ 10/ 13 Effective Date: 01/ 01/ 2014 North Dakota S14, page 2 Page 21 ot' 7

Medicaid Eligibility Additional incremental WnOUnt 6 659 6 Yes No 7 708 x Increment amount 49 8 758 x 9 807 x lo 856 x LiAdd Living Arrangement The dollar amounts increase automatically each year C Yes No AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a] I The standard is as follows: C' Statewide standard Standard varies by region ko Standard varies by living arrangement Standard varies in sorne other way Enter the standard by living arrangement L' ernove Living Arrangern Name ot' living arrangement Description I lousehold with no caretaker lousehold size Standard 1 110 x 2 208 x 294 x TH- mn- 13-MV.-AAN41 Effediva.D-ate. 0.1/ 0112014 ............ North Dakota S14, page 3 Page 3 of 7

Medicaid Eligibility I--............_......................................................................... ................................... 4 368 x Additional incremental amount is Yes C No 5 430 x Increment amount $ 6 479 x 7 51 16 x s 553 x Remove Living Arrangement Name of living arrangement Description I caretaker Household with I caretaker Household Additional incremental amount OLISehold size Standard 223 Increment al" Llrit 1. 3 2 333 x 3 431 x 4 517 x 5 591 x 6 653 x 7 7021 x 8 739 x 9 776 x Remove Living Arrangement Name of living arrangement Description Fcaretakers Household with 2 caretakers Household size Standard Ll 13 0017 MMI Date! 12/ 10/ 13 01/ 8a./.2.g.14 North Dakota S14, page 4 Piwe 4 ol' 7

Medicaid Eligibility x Additional incremental amount Yes C No 2 301 x Increment amount 3 411 x 4 5109 x 5 595 x o 661) x 7 731 8 780 9 817 lo 854 kdd Lwing,, rrangern c it The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As ofJuly 1G, 1.996 Income Standard Entry, - DollarAmount Automatic Increase Option 713a The is as follows: Statewide standard Standard varies by region C Standard varies by living arrangement Standard varies in some other Nvav The dollar arnounts increase automatically each year r Yes No jAFDC" Neal Standard in Effect As ofJuly 1G, 1996 TN: ND- 13- 0017- MM1 Approval Date: 12/ 10/ 13 Effective Date: 01/ 01/ 2014 North Dakota S14, page 5 Page 5 ot- 7

Medicaid Eligibility Income Standard Entry- Dollar Amount Automatic Increase Option S 13a w-------- The standard is as fbllotivs: Statewide standard Standard varies by region C Standard varies by living arrangement Standard varies in some other way The dollar amounts increase autornatical lv each year C Yes C' No AFDC Payment Standard inEffect 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. Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: C Statewide standard Standard varies by re- ion C Standard varies by living arrangement C' Standard varies in some other way The dollar amounts increase automatically each year C' Yes C No MAGI-equivatent AFI)C 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-AJ) since such date Income Standard Entry- Dollar Amount - Automatic Increase Option S13a The standard is as Rdlows: C Statewide standard C Standard varies by region Standard varies by living arrangement C' Standard varies in same other way. TN: ND- 13- 0017- MM1 Approval Date: 12110/ 13 Effective Date: 01/ 01/ 2014 North Dakota S14, page 6 Pave 0( 11' 7

Medicaid Eligibility u N The dollar arnounts increase autornatical1v each year TANF payment standard Income Standard Entry- Dollar Amount Automatic Increase Option Fhe standard is as lbllo vs: C Statewide standard C Standard varies by living, arrangement C Standard varies in sorne other way The dollar aniounts increase autornaticallv each vear C Yes C No Income Standard Entry- Dollar Amount Automatic Increase Option S 13a The standard is as follows: Statc, vide standard Standard varies bv reoion Standard varies by living arrangement C Standard varies in sorne other way The dollar arnounts increase automatically each year C Yes C No T. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection ofintorniation unless it display a valid OMB control number. Jhe valid OMB control nurnberk`rthis information collection iv09381148. Thc| imcrcquindu, cump| mr this information collection is estimated to avera- e 40 hours per response, including the time to review instructions, search existin- data resources, gather the data needed, and complete and review the information collection. | fyoo have comments concerning the accuracy of the hmccstin`mc( s) o, suggestions for improving this fibrin, please write to: CK4S. 7500 Security Bnu| cvnrd. Attn: PRA Reports Clearance Officer, Mail Stop C4' 26' 05. Baltimore, Maryland 2) l44-| 850. TN: wo' 13' 0017- mM1 Approval Date: 12/ 10/ 13 Effective Date: 01m1m014 North Dakota o14. page 7 Pxi4c 7 o[ 7

Medicaid Eligibility ONIB Control Number 0938- 1148 07VIB Fxpiration date: 10./31/ 2014 Eligibility Groups - Mandatory Coverage S,25 Parents and Other Caretaker Relatives 42 CF R 4:35. 1 10 1902( a)( I 0)( A)( i)( 1) 193 1( b) and( d) Parents and Other Caretaker Relatives- parents and other caretaker relatives ol' clependent children with 110LISehOld income at or below a standard established by the state. The state attests that it operates this eligibility group in accordance with the following eligibility 1 provisions: Individuals qualifying under this eligibility 2rOUP Must meet the following criteria: Are parents or other caretaker relatives( defined at 42 CFR 435. 4), including pregnant women of dependent children I defined at 42 CUR 435. 4) under age 18. Spouses of parents and other caretaker relatives are also included. The state elects the following options: his eligibility group includes individuals who are parents or other caretakers of' children who are 18 years old, E] provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. Options relating to the definition of caretaker relative( select any that apply): Options relating to the definition of dependent child( select the one that applies): Fi Have 110LIschoid income at or below the standard established by the state. MAGI- based income methodologies are used in calculating household income. please refer as necessary to SIO EI Based Income Methodologies, completed by the state. Income standard used for this group Minitnuni income standard The rninirnurn inconic standard used f6r 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 S 14 AFDC Income Standards. I he state certifies that it has submitted and received approval for its converted May L, 1988 payment standard. An attachment is submitted. Maximum income standard The state certifies that it has submitted and received approval for its converted incorne standards) for parents and other caretaker relatives to IVIM-11- equivalent standards and the determination Ofthe luaXinWITI income standard to be used for parents and other caretaker relatives under this eligibilitN, group, fin attachment is submitted. The state' s niaxiniurn income standard fior this eligibility group n rOL ) is: 3- ffT7-MMI........... Effecttve Oate-- GIMT12014 North Dakota S25, page l Page I of- 4

Medicaid Eligibility C Flie state' s effective income level For section 1931 l",nnilics under the Medicaid state plan as ol" March 23. 2010, converted to a MAGI- equivalent percent ofF11I. or',IlnOLlnts by household size. The state' s effective income level for section 19.31 families under the Medicaid state plan as ol" December 31. 2013, converted to a MAGI- equivalent, percent ofFPI, or amounts by household size. The state' s effective income level for any population ol' parents"caretaker relatives under a Medicaid I I 15 C demonstration as of March ? 3, '_ 010, converted to a MAGI- equivalent percent of IT I, or a Ill 0 Lill tS by household size. The state' s effective income level for any population of parents/ caretaker relatives Under a Medicaid I I 15 C demonstration as ot' December 31. 201. 3. converted to I MAGI- equivalent percent(:) I' Ff)[, or amounts by household size. Enter the alTIOLInt of the niaxinwin income standard: A percentage of the federal poverty level: 01' The state' s AFDC, payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. I lie standard is described in S14 AI- DC 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( CPl- U) Since such date, converted to a MAGI- equivalent standard. The standard is described in S 14 At.DC Income Standards. The state' s TANF payment standard, converted to a MAGI- equivalent standard. 'file standard is described in S14 AFDC Income Standards. Other dollar amount Income Standard Entry- Dollar Amount Automatic Increase Option S13a The standard is as follows: e- Statewide standard C' Standard varies by region C Standard varies by living,arrangement C' Standard varies in some other way e statvwidostandard TN: ND- 13- 0017- MM1 Approval Date: 12/ 10/ 13 Effective Date: 01/ 01/ 2014 North Dakota S25, page 2 ll, w,e 2 of

Medicaid Eligibility Additional incrementala IOUSehold size Standard($), Ci' Yes C No 1 517 x Increment amount S 1= 78 694 x 3 871 x 4 1, 048 x 15 1,--)-) 6 x 6 1, 403 x II 7 1, 580 x 18 1. 757 x 9 1, 934 x 10 2, 1 1 1 x The dollar amounts increase automatically each year Yes (- 0 No Income standard chosen: Indicate the state' s income standard used for this eligibility group: C The minimum income standard i' The inaxilnUni income standard The state' s AFDC payment standard in effect as oFJulv 16. 1996. increased by no more than the percentage increase in the Consumer Price Index for urban consumers( CPI- L.) since such date. The standard is described in S 14 A FDC1' Income Standards. Another income standard in- between the minimum and maximum standards allowed There is no resource test for this eligibility group. Presumptive Eligibility The-state covers individuals under this 9roup when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women( 42 CT-R 435. 116) and/ or Infants and Children under Age 19( 42 CFR 435. 118) eligibility groups when determined preSUMptively eligible. Yes (- a No TN: ND- 13- 0017- MM1 Approval Date: 12/ 10/ 13 Effective Date: 01/ 01/ 2014 North Dakota S25, page 3 Pave ', of, l

Medicaid Eligibility 0 L According m the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays o valid 0NIB control number. The valid OMB control number for this information collection isO9] 8-| \ 4X, The time n:qui/rJ| ocomplete this information collection ia estimated m average 4O hours per response. including the time w review instructions. search existing data resources, gather the data needed, and complete and review the iobonnuioo collection. If You hx, eumnmen\ s concerning the accuracy nf the time euimmc( o) o, m1.1gcminnu for improving this bnnn, please write to: CMS, 7500 Security 8ou| mon]. Attn: PRA Kcpnus[| cnmncc Officer, Mail Stop(' 4- 26- 05, Baldmorc, Maryland 2| 244'| 85O. TN: wo- 13- 0017- Mm1 Approval Date: 12110/ 13 Effective Date: 01m1u2014 North Dakota auo page Pxce4o[ 4

4C 0 Medicaid Eligibility OMB Control- Number 0938- 1148 OMB Expiration date: I0i31%?014 Tligibility Groups - Mandatory Coverage 528 PregnaI1t WomeII 42(' FR 435, 116 1902( a)( I0)( A)( i)( I11) and ( IV) 1902( x)( I0)( A)( ii)( I),( 1V) and( IX) 1931( b) and(( I) 1920 Pregnant Women- Women who are pregnant or post-partunn, with household income at or below a standard established by the state. E,(] The state attests that it operates this eligibility group in accordance with the followirng provisions: i 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 oftheir pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 Cl, R 435. 1 10. C Yes ( i No MAGI- based income methodologies are used in calculating household income. Please refer as necessary to S 10 MAGI- Based Income Methodologies. completed by the state. 3 i Income standard used for this group i Minimum income standard( Once entered and approved by CNIS. the minimum income standard cannot be changed.) The state had in income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July I. 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 submit ed and received approval for its converted income standard( s) for pregnant V women to MAGI-equivalent standards and the determination of the maxintun income standard m be used for- pregnant women under this eligibility group. An attachment is submitted. The state' s maximum income standard for this eligibility group is: The state's highest effective income level for coverage of pregnant women under sections 1931 ( low- income families), 1902( a)( 10)( A)( i)( 111)( qualified pregnant women), 1902( a)( 10)( A)( i)( IV)( mandatory poverty level- related pregnant women), I902(a)( I0)( A)( ii)( IX)( optional poverty level- related pregnant women), 1902( x)( 10) A)( ii)( 1)( pregnant women who meet AFDC.' financial eligibility criteria) and 1902( x)( I0)( A)( ii)( IV) institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN: ND- 13- 0017- MM1 Approval Date: 12110/ 13 Effective Date: 01/ 01/ 2014 North Dakota S28, page 1 Page 1 of 2

Medicaid Eli i == ty The state' s hioliest effective income level for coverage of pregnant women under sections 193 1 ( low- income families'), 1902( a)( 10)( A)( i)( 111)( qualified pregnant women,), I() O'Z.( a)( 10)( A)( i)( IV)( mandator, poverty level- related preonant wornen), 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)( IV) institutionalized pregnant women) in effect under the Medicaid state plan as of December 3 1, 2013, converted to a MAGI- equivalent percent off' I' L. Fhe state' s effective income level for any population ofpregnant women tinder a Medicaid I I 15 demonstration as oil' March 23, 20 10. converted to a MAGI- equivalent percent ofl.PL. Fhe state's effective income level for any population ofpregnant women tinder a Medicaid I I I demonstration as of December 3 1, 20 13, converted to a MAGI- ccluivalent percent MITI- 1 851',o FTIL income standard chosen Indicate the state' s income standard used for this elioibility group: C' The maxitnum income standard e Another income standard in- bet\,veen the minimum and MaXiMURI standards allo\, ed. I he arnount ofthe income standard for this cli(Yibility group is: El There is no resource test for this eligibility( 1,,roup. Beflefits ft)r individuals in this eligibility group consist of the R)llowing: i A 11 pregnant vorncn cligible under this roup receive full Medicaid coverage under this state plan. Pregnant women vvhose income exceeds the income limit specified below lor [ Lill coverage of pregnant kvoinen receive only pregnancy- rclated services, The stale covers ambulatory prenatal care for individuals 1. 111der this group whcn deteri-nined presumptively eligible bv a qualified entity. PRA 1) According to the Paperwork Reduction Act of 1995. no persons are required to respond to a collection ofinforination unless it displays a vandOKiBcon/ m| oumho. Thovx|idOMBcomm| numhrck`rdhiniu| bmmboncoUecxionis093X| } 48. Thchm* rcguindmcump| mc this inkmnmion collection ix estimated m average 4V hours per response. including the time mreview instructions, search cxistinodux n`^ouncs. mhc, tbcJumnc dmj. andcon p|* condroviuw/ h in[ hrmoz nuco|| ochox | fyoohov uommm( acouconix the occur yof the time cs6mu/ms> n, suggestions for improving this form, please write to: CMS` 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop[ 4- 26- 05. Baltimore, Maryland 2l244'| 8j0. TN: mo' 13- 0017' wm1 Approval Date: 12/ 10/ 13 Effective Date: 01m1m014 North Dakota nu8, page z Pomc2o[ 2,

Medicaid Eligibility OMB Control Numbei- 0938- 1148 ON413 Expiration date: 10/ 31/ 2014 Eligibility Groups - Mandatory Coverage S30 Infants and Children under Age 19 42(-' F R 435. 1 18 I 902( a)( I 0)( A)( i)( 11 I) t( IV),( VI) and ( V11) 1902( a)( I 0)( A)( i i)( 1 V) and ( IX) 193 1( b) and( d) Infants and Children under Age 19- Infants and children under age 19 with household income at or belovv standards established by the state based on age group. J lie state attests that it operates this eligibility group in accordance with the f6flowing provisions: Children qualifying under this eligibility group must meet the following criteria: qualifying 11 Are under age 19 Have household income at or below the standard established by the state. MAGI- based income methodologies are used in calculating household income. Please refer as necessary to S 10 MAGI- Based Income Methodologies., completed by the state. Income standard used for infants under age one Minimum inCOIT] e standard The state had an income standard higher than 13311,'0 FPL established as ol" December 19, 1989 for determining eligibility foi infants Under age one, or as ot'July 1. 1989, had authorizing, legislation to do so. Yes Co' No The miniFullin income standard for infants under age one is 133`, o FTL. MaxinWin income standard The state certifies that it has submitted and received approval for its converted income standard( s) for infants under age one to MAGI- equivalent standards and the determination of the ma.\,irnurn income standard to be used for infants under aue one. An attachment is submitted. The state' s maximum income standard for this group roup is: t) 1 The state' s highest effective income level for coverage of infants under age one under sections 1931 ( low- income families), 1902( a)( I 0)( A)( i)( 111)( qualified children), 1902( a)( I 0)( A)( i)( IV)( mandatory poverty level- related infants), 1902( a)( I 0)( A)( ii)( IX)( optional poverty level- related infants) and 1902( a)( I 0)( A)( ii)( I V) institutionalized children), in effect under the Medicaid state plan as of' March 23, 2010, converted to a MAGI- equivalent percent of FPI_ TN: ND- 13- 0017- MM1 Approval Date: 12/ 10/ 13 Effective Date: 01/ 01/ 2014 North Dakota S30, page l Page I of

m S Medicaid Eligibility The state' s highest effective income I eve I for coverage of infants Under age one under sections 1931 ( Iow- income families), 1902( a)( 10)( A)( i)( 111)( qualified children), 1902( a)( 10)( A)( i)( W)( mandatory poverty level-related infants), 1902( a)( 10)( A)( ii)( I X)( optional poverty level- related infiants) an( I 1902( a)( 1 0)( A)( ii)( IV) institutionalized children)., in effect Under the Medicaid state plan as of December 31. 2013, converted to a VIAGI- equivalent percent of FPL. C, ' fire state' s effective income level for any population of infants under age one Under a Medicaid I I 15 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL C The state' s effective income level for any population of infants under age one under a Medicaid I 115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL Ce 18 5 IN) FPL 1i] Income standard chosen The state' s income standard used for infants under age one is: C The maximum income standard If not chosen as the maximum income standard, the state' s highest effective income level for coverage of infants- under age one under sections 1931 ( low- income families), I 902( a)( I 0)( A)( i)( 111)( qualified children), 1902( a)( 10) A)( i)( IV)( mandatory poverty level- related infants), 1902( a)( I 0)( A)( ii)( IX)( optional poverty level- related infants) and 1902( a)( 10)( A)( ii)( W)( institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL If hi- her 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 inaxilnLull income standard, the state' s highest effective income level for coverm_,e ofinfamns under my-e one under sections 1931 ( low- income families), I 902( a)( I 0)( A)( i)( 11 1)( qualified children), 1902( x)( 10) A)( i)( IV)( mandatory poverty level- related infants), 1902( a)( 10)( A)( ii)( IX)( optional poverty level- related infants) and 1902( a)( I 0)( A)( ii)( IV)( institutionalize(] children), in effect under the Medicaid stale plan as of December 31, 20 13, converted to a MAGI- equivalent percent of 1- 11L. If higher than the highest effective income level for this age group Under the state plan as of March 23, 2010, and t, 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 N'larch 23, 2010, and C if not chosen as the maximum income standard, the state' s effective income level for any population of infants under- age one under a Medicaid I I I5 demonstration as ot' December 31, 2013, convened to a MAGI- equivalent percent of FPL. Another income standard in- between the ininin)(fln and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 21, 2010. The arnount of the income standard for infants under- one is: 147 ° io FPL Income standard for children age one through age five. inclusive Do Minimum income standard TN: ND- 13- 0017- MM1 Approval Date: 12110/ 13 Effective Date: 01/ 01/ 2014 North Dakota— T S30, page-2 Nu-'e 2 of

MIS" Medicaid Eligibility The minimum income standard used l6r this age group is 133%6 1 Pl_ Maximum income standard The state certifies that it has submitted and receive(] approval for its converted income standard( s) I'or children age one through five to MAGI- equivalent standards and the determination of the maximum income standard to be used for children we one through Five. An attachmentis submitted. The state' s maximum income standard for children age one through five is: The state's highest effective income level for coverage ol' children age one through Five under sections 1931 Oom- Z., income families), I 902( a)( I 0)( A)( i)( I 11)( qualified children), 1902( a)( I 0)( A)( i)( VI)( mandatory poverty level- related children age one through five), and 1902( a)( I 0)( A)( ii)( I V)( institutionalized children). in effect Under the Medicaid state plan as of' March 23, 2010, converted to a MAGI- equivalent percent of' FTL The state' s highest effective income level for coverage of children age' one through Five under sections 1931 ( lo\ v- income families). 1902( a)( 10)( A)( i)( 111)( qualified children). 1902( a)( I 0)( A)( i)( VI)( mandatory poverty level- related children age one through five), and 1902( a)( I 0)( A)( ii)( IV)( institutionalized children), in affect tinder the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FP1_ The state's effective income level for any population of children age one through five Under a Medicaid 1115 C demonstration as ot' March 23. 2010. converted to a MAGI- equivalent percent of FPI_ The state's effective income level for any population of children age one through five Under a Medicaid 111 C, 5 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent ol' FPI.. Enter the amount of the maXiInUin income standard: ITI, Em Income standard chosen The state' s income standard used for children age one through five is: Ce The maximum income standard If' not chosen as the maxiinUlln income standard, the state' s hi- hest effective income level for coverage of' children age one through five Under sections 1931 ( low- income Families). I 902( a)( I 0)( A)( i)( 111)( qualified children), 1902( a)( 10)( A)( i)( V 1)( mandatory poverty level- related children age one through five), and 1902( a)( I 0)( A)( ii) IV)( institutionalized children), in effect under the Medicaid state plan as ol' 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 C age one through five under sections 1931 ( low- income families), 1() 02( a)( 10)( A)( i)( 111)( qualified childi-eii), 1902( a)( I 0)( A)( i)( VI)( mandatory poverty level- related children age one through five), and 1902( a)( I 0)( A)( ii) IV)( institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of HIL, TN: ND- 13- 0017- MMI Approval Date: 12/ 10/ 13 Effective Date: 01/ 01/ 2014 North Dakota 530, page 3 Page 3 of

Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of' March 23, 2010, and C if not chosen as the maximum income standard, the state's effective income level for any population Of children age one through Five Under a Medicaid I 115 demonstration as of March 23, 2010, converted to a NIAGI- equivalent percent ofFPL. If higher than the highest effective income level for this age group under the state plan as of;March 23, 2010, and C if not chosen as the maximum income standard, the state' s effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent ofFPI.. C Another income standard in- between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as oflMarch 23, 2010. Income standard for children age six through age eighteen, inclusive C Minimum income standard The minimum income standard Used for this age group is 1339,) 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. An attachment is sullmnitted. The state' s maximum income standard for children age six through eighteen is: Z-1 The slate' s highest effective income level for coverage of children age six through eighteen under sections 1931 low- income families), 1902( a)( I 0)( A)( i)( 111)( qualified children), 1902( a)( 1 0)(. A)( i)( VI 1)( niandatory poverty en al. level- related children six through eighteen) and F 02( a)( I 0)( A)( ii) IV)( institutionalized children,), in eff Under the Medicaid State plan as ol.'March 23, 2010, converted to a MAGI- equivalent percent of UPL. The state' s highest effective income level for coverage ot' children age six through eighteen Under sections 1931 low- income families), I 902( a)( I 0)( A)( i)( 111)( qualified children). 1902( a)( 1 0)( A)( i)( VI 1)( mandatory poverty level- related children a(,c' t' c' c six through eighteen) and 1902( a)( 10)( A)( ii)( IV)( institutionalized children), in effect Under the Medicaid state plan as of December 31, 20 13, converted to a MAGI- equivalent Percent Of U' PL, C The state' s effective income level for any population of children age six through eighteen under a N'ledicaid I 1 15 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPI.. The state' s effective income level for any population of children age six through eighteen under a Medicaid 11 15 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent ofFP1 r* 13 3'),'o FP L Income standard chosen The state's income standard Used for children age six through eighteen is: TN: ND- 13- 0017- MMI Approval Date: 12/ 10/ 13 EffeEtive ate: 01/ UU2 14 North Dakota S30, page 4 Page 4 ot',

Medicaid Eligibility b The inaximurn iuC01ne standard If not chosen as the maximurn income standard, the state' s highest effective income level for coverage of children age six through eighteen under sections 193 1 ( low- income fiarnilies), 1902( a)( I 0)( A)( i)( I 11)( qualified children). 1902( a)( I 0)( A)( i)( VII)( mandatory poverty level- rclated children age six through eighteen) and I 90-1( a)( I 0)( A) ii)( IV)( institutionalized children), in effect under the\ Mcdicaicl state plan as of N-larch 2'.,, 20 10, converted to a MAGI- eqUiValent Percent Of FPL If higher than the highest effective income level fbr this age oroup under the state plan as of March 2.3. 20 1 O and it' not chosen as the rnaNilntlul iuCOFuc standard, the state' s highest effective income level for coverage ofchildren C age six through eighteen under sections 193 1 ( low- income fiarnilies), I 902( a)( I 0)( A)( i)( 11 1)( qualified children), 1902( a)( I 0)( A)( i)( VII)( mandatory poverty level- related children age six through eighteen) and 1902( a)( I 0)( A ii)( lV)( institutionalize(] children), in ef let under the Medicaid state plan as ot' Decernber 3 1, 2013, converted to a MAGI- equivalent percent ofF'PL. If higher than the highest effective income level for this age- roup under the state plan as ofMarch 23, 20 10. and C if not chosen as the maximum income standard, the state' s effective income level for any population of children age six through eighteen under a Medicaid I I 15 dernonstration as of March 21, 2010, converted to a NJAGI- equivalent percent of FPL If higher than the highest efrective income level for this age group under the state plan as ofMarch 21, 20 10, and C if not chosen as the maximum income standard,( lie state's effective income level for any population ot'children a- c six tlirou- h ei- liteen under a Medicaid 1115 dernonstration as of' December 3 1, 2013, converted to a N/lAGI- Another inCOITIC stindard in- between the mininium 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, 20 10, There is no reSOUrce test for this el igibil ity group, Presumptive Eligibility The state covers children Nhen determined presumptively eligible by a qualiked entity. PRA i Statement According( o cPmperwo, kKedocdnuAun[| 9Y5` ompmsonymrmquiodmnopoodmncnUcc( kono[ inh`onmionoo| cs» itJisp|uysu valid OKi8 000xo| number. The valid 0M8 onnun| uomhcr for this information md| cchoo is 0938- 1148. The time mqoiod to complete this iofbonmino collection is estimated m average 4U hours per response. including the dmc\ o review ins/ mcxions. search oishxgdau resources, gather the data needed, and complete and review the inflormation collection. Ifyou have comments concerning tile accuracy Of the time cs/ imam( v) orsuggestions for improving this k`on, please write to: CMS. 7500 Security Bnu| cvmn|, Attn: PRA Reports Clearance Officer, Mail Stop C4' 2o05. Baltimore, Nary|uod2| 244 1850. TN: mo' 13' 0017' Mm1 Approval Date: 12/ 10/ 13 Effective Date: 01m1/ 2014 North Dakota oou. page n Puue o[

Medicaid Eligibility OM13 Control Number 0918- 1148 OMB Fxpiration date: 10/31/ 2014 Eligibility Groups - Mandatory Coverage, S32 Adult Group 1902( a)( 1 0)( A)( i)( VII 1) 42 CFR 435. 1 19 The state covers the Adult Group as described at 42 CFR 435. 119. YrCS C No Achill Group- Non- pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133')« FIT, he 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: Have attained ay 19 but not age 65. I-m] Are not pregnant. Are not entitled to or enrolled for Part A or B Medicare benefits. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B. Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory Medicaid eligibility due to mot e restrictive requirements may quali y for this eligibility group il'otherwise eligible I lave household inconic at or below 131`, o FPL MAGI- based income methodologies are used in calculating household income. Please refer as necessary to S 10 MAGI- Based Income Methodologies, completed by the state. F There is no resource test for this eligibility group. Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is receiving benefits under Medicaid. CHIP or through the Exchange. or otherwise enrolled in minimum essential COVe1' agC, as defined in 42 CFR 435. 4. Under age 19, or 6_io A higher age of children, if any, covered under 42 CFR 435. 222 on March 23, 2010: C Under age 20 6 Under age 21 Presumptive Eligibility The state covers individuals under this group wizen determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women( 42 CFR 435. 1 16) and/ Or Infants and Children under Age 19( 42 CUR 435. 1 18) eli- ibilily groups when determined presumptively eligible. C, Yes re, No TN: ND- 13- 0017- MM1 Approval Date: 12110/ 13 Effective Date: 01/ 01/ 2014 North Dakota S32, page l Page 1 of 2

Medicaid 0 0[ 00 0 NNN 7 i According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection ofinforination unless it displays a valid OMB control number. The valid ON/113 control Munber 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 inmmcdnns, ycmzh c` iuioo data resources. gather the data needed, and complete and review the information c011eCti0r). If You have comments concerning the accuracy of the time emimmo( o) orsu(;&c iuno 6», impmving this form, p| cmcwrite W: C 8. 7500 Security 8ou|cvud` Attn: PRA Reports Clearance 0ffic* c &1ai| SwpC4 26O. Baltimore, Maryland 2| 244'| 85O. TN: wo' 13- 0017- Mm1 Approval Date: 12n0/ 13 Effective Date: 01/ 01x201* North Dakota nnc page PowcZof-I

Medicaid Eligibility OMR Control NumberDP38'| \ 48 OK1BEx Expiration date: | 0S| 2O14 Eligibility Groups - Mandatory Coverage S33 Former Foster Care Children CFR 43 5, 150 Former Foster Care Children- Individuals under the age of' 26, riot otherwise mandatorily eligible. who were oil Medicaid and in f6ster care when they turned age 18 oi- aged out of foster care. The state attests that it operates this eligibility group Under the fiellowing provisions: IndiVidUals qualirying under this eligibility group must nicel the following criteria: F Are under ag1c 26. Are riot olllemise eligible for and enrolled 1`4 Mandatory coverage under the state plan, except 1hat eligibility UndCr this group takes precedence over eligibility under the Adult Group. Were in foster care under the responsibility ofthe state or I ribe and were enrolled ill Medicaid under the state' s state plan or I 115 dernonstration when they turned 18 or at the time ofaging ow ofthal. state' s or Fribe' s foster care The state elects to cover chi ldren who were in foster care and oil Medicaid in anv state at the lime they turned 18 or aged out ofthe foster care systein, he state covers individuals Under this gronp when determined preSUIllptiVeIV eligible by a qualificd entity. The state assurct it also covers individuals under the Pregnant Women( 42 CFR 435. 116) and/ or Infants and Children under ALc 19( 42( T'R 435. 118) eli- ibility groups when determined preSUluptively eli- ible. According to the Paperwork Reduction Act of 1995. 110 persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control nUiriber for this information collection is 0938 1148, The thile reqUiredto complete this information collection is CStilTialed to average 40 hours per response, including the dmeu, review inwrxuioos` search existing data resources. gather the data needed, and complete and review the inlorination collection. Ifyou have comments concerning the accuracy of' the/ imexuimmzr( s) orsuggestions for improving this fonn. please write to: CMS, 7500 Security Boulevard, Attn: PRA RcpnrtsOcnrmnce Officer. Mail Stop[ 4- 26' 05. Baltimore, Maryland 2| 244'| 850 TN: wo' 13- 0017- MM1 Approval Date: 12n0n3 Effective Date: 01m1o014 North Dakota son page 1 Poce | o[}

Medicaid Elig=b~l~ty OMB Control% umb0r0Y] 8'\ i48 OMB Ex iouiondote: | U/ 3\/` O| 4 Eligibility Groups - Options for Coverage S50 42 CFR 435, 2 18 Individuals above 133'!/ o IFTL-' I he state elects to cover individuals under 0. not otherwise mandatorily or optionally eligible with income above 1313 1, ITL and at or below a standard established by the state and in accordance , vith provisions described at According to the Papervvork Reduction Act of 1995, no persons are required to respond to a collection of ink)rniation unless it display's a valid OKJ8 control number. The valid OMB control number for this inCbmlo1ioo collection iy0938-| | 48, The time required mcomplete this information collection is estimated Wovcmp c40hounpor/ spoosc, inc\ udin 1hczimcmnvicw numodons` ocmch ximin data resources. - ather the data needed, and complete and review the information collection. | f you have commuo/ o concerning the ucwmc} o[ the time egimutds) nrm gc m ionx K`, improvio U i K` rm. p| cuu: w, i c : CWS. 7500 Security Bou1ovuod, Attn: PRA Reports Clearance Officer. Mail Stop[ 4- 26-Oi Baltimore, Maryland 2| 244-| 80. TN: mo' 13- 0017- Mm1 Approval Date: 12/ 10/ 13 Effective Date: 01m1m014 North Dakota soo page

Medicaid 0l0g~bNNi~y O%,I8 Control Nun` hcr0V38-\\ 48 0`0 BFx iogiondate: | U/ 3|/- 20\ 4 Eligibility Groups - Options for Coverage S51 Optional Coverage of Parents and Other Caretaker Relatives 42 CFR 435220 Optional Coverage of Parents and Other Caretaker Rehilives- flie slate elects to cover individuals qualifying as parents orolher caretaker relatives who are not mandatorilly cligible and who have income at or bc] oNv a standard established by the state and in accordance with provisions described at 42 CFR 435. 220 PRA Disclosure Statemertt According to the Paperwork Reduction Act of 1995, no pet-sons are required to respond to a collection of information unless it displays a valid UK1B control oomhur. The valid OMB control number for this information collection i` O93X-| | 48, Tfie time required mcomp}ctr this information collection is estimated m average 4O hours per response, inuludino the time ton, ic* instructions, search oigiuL data c»oorcc». gohc, thcdoaonccdcd, uudcomp| cucuudmvicwthein[ unnubonco|| euion. | fVou have comments cooucmioo, the accomc} ol' the time cuimme( s) orouogcstiuns for improving this form, please write w: Chl8. 7500 Sccuri[} Bou| nvaod, Auu: PRA Reports Clearance Officer. Mail Stop C4- 26- 05, Baltimore, Maryland 2| 244-) 85O. TN: mo' 13* 017- Mm1 Approval Date: 12/ 10n3 Effective Date: 01m1/ 2014 North Dakota so1. page I Powc \ of|

Medicaid Eligibility OMB Control Number 0938- 1148 0\ 113 Expiration date: 10/ 31; 2014 Eligibility Groups - Options for Coverage S52 Reasonable Classification of Individuals under Age 21 42( R 435. 222 1902( a)( 10)( A)( i i)( 1) 1902( a)( 10)( A)( ii)( 1V) Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classirications 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. Ycs tW No PRA Disclosure Sta_tcm_ent 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 inforrrratiort collection. Ifyou have cornments concerning the accuracy of the time estirnatc( 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: ND- 13- 0017- MM1 Approval Date: 12/ 10/ 13 Effective Date: 01/ 01/ 2014 North Dakota S52, page 1 Pau,e 1 of I

Medicaid l 0 0 0N0 7 OMB Contm| Number U93Q-\| 4X ONJ8 Expiration dntc | O/ 3|/` 0| 4 Eligibility Groups - Options for Coverage Child rcn' withl on IV-E Adoption Assistance 42 CFR 435. 227 Children with Non IV- F' A(loplion Assistlance- The state elects to cover chi ldren NN ith special needs for whom there is a non I V- F adoption assistance agreelflent in effect with a stale. kho were eligible fOr Medicaid, or who had income at or below a standard established by the state and in accordance with pro isions described at 42 CU'R 435. 22T lie state attests that it operates this eligibility group in accordance with the following provisions: IndiVidUals qualifyino under this eli- ibility group must meet the follo N ing criteria: I he state adoption agency has determined that they cannot be placed without Medicaid coverage because Of Special F- 01 needs for medical or rehabilitative care; Are under the tollowing age( see the Guidance for restrictions on the selection ol' an age): 1. 1 rider age 20 I.Inder age 19 NIAGI- based income methodologies are use(] in calculating household income, Please rel'cras necessary to S 10 MAGI- Based Income Meth0d0lOgieS, C0111PICICCI by the state. The state covered this eligibility group in the Medicaid state plan as of December 3 1, 20 13, or under a Medicaid I 11 4; Demonstration as ofMarch 23.—10 10 or December 3 1. 20 13. The state also coveredthis eligibility group in the Medicaidstate planasofMarch 23. 2010 Yes C No Individuals qualifV Under this eligibility group if they were eligible under the state' s approved state plan prior to the execution of the adoption agreement. I lie state used an income standard or disregarded all incorne f6r this eligibility group either in the Medicaid state plan as of' March 23, 20 10 or December 31, 20 11, or under a Medicaid 1115 I) cnionstration as of March 23, 20 10 or December 3 1, 2013. here is no resource test for this eligibility group. PRA Disdnsun8t/ temcni According| o the Paperwork Reduction Act of| 995. Jk` u collection oCin('onnu' ionuu| c»sk displays o valid OMB 000tm| number. The valid OMB cnotm| number for this information collection isO9] 8'| 148. The time required to Complete this information on|| cz/ ioo io estimated/ o average 40 hours per response. including the time/ o review instructions. search existing data resources, gather the data needed, and complete and review the information collection. | f you have comments concerning the accuracy of the time cmimute( o) o, avy-tycs` ions for improving this form. Please write to: CMS, 7500 Security Bno| cvun|. Attn: PRA RcyuusC\ mmnce OfUcc,. Mail Stop[ 4- Z6' 05. Baltimore. Maryland 2| 244-| 85O. TN: wo' 13- 0017' mm1 Approval Date: 12/ 10/ 13 Effective Date: 01m1o014 North Dakota aon. pagol Poue } o[|

Medicaid Eligibility 0N1B Control Number O93D' i ! 4X O)1B Expiration date: 1081 2O14 Eligibility Groups - Options for Coverage S54 Optional TargetedLow Income Children 42 CFR 435. 229 and 435. 4 i Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition oroptional targeted low income children at 42 CFR 435. 4. who have household income at or below a standard established bv the state in(] in accordance with provisions described at 42 CI' R 435- 21-9. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection ofintorniation unle"", it displays a valid OK4H control number. The valid Ok4B control number for this information collection is 0938-| | 48. Tlie 6mc required mcomplete this information collection is estimated Wuvom o40houm per zrsponsc, induJio the dmcWovicvingruc/ imna` sewzhczi io d u resources. gather the data needed, and complete and revie the itil'brination collection. | f you have comoieotoconcerning the uouumc) o[ the time* stimmus) nrsuggestions for improving( his form, please\, v, itcm: CMS. 75UU 8ccur6, Bou| c, unJ. Attn: PRA Reports Clearance Officer, Mail Stop[ 4' 26- 05. Baltimore. Maryland% l244- iX5O. TN: wo' 13' 0017' mm1 Approval Date: 12/ 10/ 13 Effective Date: 01m1m014 North Dakota o54. pamrl

Medicaid | 0ND/ Eligibility OMB Control Nun/ bc/ 09] X'|\ 48 OMB Expiration dote: | U/ 3|/` O| 4 ti'] Eligibility Groups - Options for Coverage Individuals with Tuberculosis Individuals with Tuberculosis- The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tUbcrculosis- related services. According to the Papcnvod. KeJuodon Act of) 995, nnpersousororcqoincdmrcspoodwu collection ofio| oonodnn unless i/ displays u valid OMB control number. The valid OMB control number for this information collection isO9] X'|| 48, The time required mcomplete this iuk`nnmion moUco\ imn is estimated m average 40hours per response. including the time to pcvicn instructions. search existing data resources, - ather the data needed. and complete and review the information collection. if YOU have cnmmcnmcoocen, ing the accuracy of the lime estimate( s) or Suggestions for improving this t6rm, please write to : CNIS. 7500 Security Boulevard. Attn: PRA Reports Clearance OfU» nr. Mail Stop C4- 26- Oj. Baltimore, Maryland 2\ 244-| 850. TN: wo- 13- 0017' mM1 Approval Date: 12110/ 13 Effective Date: 01m1o014 North Dakota non. page 1

Medicaid Eligibility OMB Control Number 0938- 1148 O' 0B Expiration date: 10/ 31/ 2014 Eligibility Groups - Options for Coverage S57 Independent Foster Care Adolescents W.... .._._ __. w_ W......__.._...... _._._......._..-___......._.....__....._.__..... 42 CFR 435, 226 1902( a)( 10)( A)( ii)( XVII) Independent Foster Care Adolescents- The state elects to cover individuals under an age specified by the state, less than a- e 21, who were in state- sponsored foster care on their 1 8th birthday and who meet the income standard establislicd by the state and in accordance with the provisions described at 42 CFR 435. 226. 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- 11, 48, 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 continents 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: ND- 13- 0017- MM1 Approval Date: 12/ 10/ 13 Effective Date: 01/ 01/ 2014 North Dakota S57, page 1 Pau I of l

Medicaid Eligibility Cj: OMB Control Nuunhc, 89J0-|\ 48 01013 Fxpiration date: | U/ 3|/` 8| 4 Groups - Options for Coverage hidividuals Eligible for Family Planning Services 142 CFR 435, 214 Individmils Eligible for Family Planning Services- The state elects to cover individuals,, Nho are not pregnant. and have household annik planning and related services and in inconne at or below a standard established by the state. whose coverage is limited to fi accordance with provisions described at 42 CFR 435. 214. PRA Disclosut-e Statement AccordingtothePaperwork Ru|w:/ ion4duf| 99iuupei-sonsmcnquindmuupundmnumUcohmno[ infbnmoainn unless i/ diop| oysu vu| id0N8cuntm| numher. The valid 0NB control number for this inbunmiou collection ioD93X' ll4V. [ hchmemquindmcomp| mu this information collection is estimated m average 4O hours per response, including tho time to review instructions, yommh existing data rruouocs. gather the damneeded, and complete and , evinm the ixk,/ mu! ioo collection. [ f you have comments concerning the accuracy of thedmrmdmu/6u} nrouWITcohonSh/ rimpmving| hisfbrm. p| ouucvriie1o: CNS, 7500Socori/ y800\ m/ un].& mcPRXRcpons[| cmnxcc Officer, >dai| Stop(' 4- 26- O5. Baltimore, 4my\and2l244'| A5O. TN: wo' 13- 0017' MM1 Approval Date: 12/ 10/ 13 Effective Date: 01m1m014 North Dakota soe. page 1 Pu_)c ! of' I

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: ND-13-0019-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Superseding Pages Notice 4) Approved SPA Pages TN: ND-13-0019-MM Approval Date: 3/25/14 Effective Date: 1/1/14

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Denver Regional Office 1600 Broadway, Suite #700 Denver, CO 80202 -4967 REGION VIII - DENVER April 1, 2014 Julie F. Schwab, Medicaid Director North Dakota Department of Human Services 600 E. Boulevard Ave, Dept. 325 Bismarck, ND 58505 -0250 Dear Ms. Schwab: MS CENTERS FOR MEDICARE & MEDICAID SERVICES We have reviewed the proposed MAGI State Plan Amendment ( SPA) submitted under transmittal number ND- 13- 0019 -MM. This SPA implements the new provision for MAGI Income Methodologies under the Affordable Care Act. Please be informed that this State Plan Amendment was approved March 25, 2014 with an effective date of January 1, 2014. Enclosed is a copy ofthe new State Plan pages to be incorporated within a separate section at the back ofNorth Dakota' s approved State Plan: S10, pages S10- 1 and S10-2 In addition, enclosed is a summary of State Plan pages that are superseded by SPA ND -13- 0019 -MM, which should also be incorporated into a separate section in the front of the State Plan: Superseding pages of State Plan Material, ND -13- 0019 -MM The enclosure incorporates the following statement into the North Dakota State Plan: Notwithstanding any other provisions of the North Dakota Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment 13- 047 -MM will apply to all MAGI -based eligibility groups covered under North Dakota' s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.6030) for whom MAGI -based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI -based eligibility groups." CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Ann Clemens at (303) 844 -2125 or ann. clemensgcros.hhs. gov. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations

State/Territory name: North Dakota Submitted By: Maggie Anderson Last Revision Date: Mar 18, 2014 Submit Date: Oct 24, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. ND-13-0019 Proposed Effective Date 01/01/2014 ( mm/ dd/ yyyy) Federal Statute/Regulation Citation 42 CFR 435.603 Federal Budget Impact Federal FiscalYearAmount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Affordable Care Act - Medicaid Eligiblity State Plan Amendments - MAGI Income Methodology. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Single State Agency is responsible for the review and submission of Medicaid state plan amendments without review of the Governor's office. Signature of State Agency Official Page 1of 2ND. 0449.R00.00 - Jan 01, 2014 03/28/ 2014http:/ 157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp TN: ND-13-0019-MM North Dakota Approval Date: 03/25/14 Effective Date: 01/01/14

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: 13-0019 STATE: North Dakota PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: S10 - MAGI Income Methodology PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Notwithstanding any other provisions of the North Dakota Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment 13-0019 will apply to all MAGI-based eligibility groups covered under North Dakota’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI -based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups. TN: ND-13-0019-MM North Dakota Approval Date: 03/25/14 Effective Date: 01/01/14

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 MAGI-Based Income Methodologies S10 1902(e)(14) 42 CFR 435.603 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. The pregnant woman is counted as herself, plus one. The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: Current monthly household income and family size 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: 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. Yes No TN: ND-13-0019-MM North Dakota Approval Date: 03/25/14 S10, page 1 Effective Date: 01/01/14

Page 2 of 2 Medicaid Eligibility The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is: Age 19 Age 19, or in the case of full-time students, age 21 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: ND-13-0019-MM North Dakota Approval Date: 03/25/14 S10, page 2 Effective Date: 01/01/14

Table of Contents

State/Territory Name: North Dakota State Plan Amendment (SPA) #: 13-0022-MM6 This file contains the following documents in the order listed: 1) Revised Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th Street, Suite 355 Kansas City, MO 64106

Medicaid & CHIP Operations Group

April 6, 2021

Caprice Knapp, Medicaid Director Division of Medical Services North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250

RE: North Dakota State Plan Amendment (SPA) 13-0022-MM6 Dear Ms. Knapp: We are sending this revised approval package because in discussion with your staff we identified that, the superseding document that was part of the original approval package contained an error. We have corrected the error, so please replace the original approval package with this one. Sorry for any inconvenience.

North Dakota’s State Plan Amendment (SPA), submitted under transmittal number (TN) ND-13-0022- MM6, was approved on January 16, 2014, with an effective date of January 1, 2014. With this SPA, the State affirmed citizenship regulations, specified reasonable opportunity options, and, specified policy options related to immigrant eligibility in accordance to the Affordable Care Act.

With this corrected SPA package, we are enclosing the summary page (formerly CMS 179) and the amended plan page(s).

Should you have any questions about this amendment, please contact Curtis Volesky at (303) 844-7033, or by email at Curtis.volesky@cms.hhs.gov.

Sincerely,

James G. Scott, Director Division of Program Operations

cc: Krista Fremming, krfremming@nd.gov Stacey Koehly, skoehly@nd.gov LeeAnn Thiel, lthiel@nd.gov

Maggie Anderson, maganderson@nd.gov

Digitally signed by James G. Scott -S Date: 2021.04.06 17:33:18 -05'00'

ND.0445.R00.00 - Jan 01, 2014 Page | of 2

Medicaid State Plan Eligibility: Summary Page (CMS 179)

State/Territory name: North Dakota

Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.

ND-13-0022

Proposed Effective Date 01/01/2014 (mm/dd/yyyy)

Federal Statute/Regulation Citation 42 CFR: 435.4; 435.406, 435.956

Federal Budget Impact

Federal Fiscal Year Amount First Year 2014 $0.00 Second Year 2015 $0.00 Subject of Amendment

Affordable Care Act - Medicaid Eligibility State Plans - Bucket 6 -Citizenship and Immigration status.

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

Comments of Governor's office received Describe:

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

The Single State Agency is responsible for review and submission of Medicaid State Plan amendments, without review and approval of the Governor's office.

Signature of State Agency Official

Submitted By: Maggie Anderson

Last Revision Date: Jan 8, 2014

Submit Date: Oct 23, 2013 TN: ND-13-0022-MM6 Approval Date: 01/16/14 Effective Date: 01/01/14 North Dakota

http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 01/21/2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER: STATE:

TN-ND-13-0022 North Dakota

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

S89 Non-Financial Eligibility-Citizenship and Non-Citizen | Attachment 2.6-A, Page 2, Item 3, TN 92-010 Eligibility Attachment 2.6-A, Page 3, Item 3, Subparagraphs (d) and (e), 08-003

TN: ND-13-0022-MM6 Approval Date: 01/16/14 Effective Date: 01/01/14 North Dakota

CCmMS Medicaid Eligibility

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

Non-Financial Eligibility S89 Citizenship and Non-Citizen Eligibility .

1902(a)(46)(B)

S$ ULS.C. 1611, 1612, 1613, and 1641 1903(v(2).(3) and (4)

42 CFR 4354

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.

{] 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 fm] 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 immigration status, during a reasonable opportunity period pending verif

oh ation 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.

@Yes CNo

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 © No The date benefits are furnished is: C The date of application containing the declaration of citizenship or immigration status.

C The date the reasonable opportunity notice is sent.

(@ Other date, as described: The first day of the month of the application containing the declaration of citizenship or immigration status.

TN: ND-13-0022-MM6 Approval Date: 01/16/14 Effective Date: 01/01/14 North Dakota S89, Page 1

Page | of 3

Medicaid Eligibility

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

C Yes @No Indicate which requirements apply: The state requires Lawful Permanent Residents to have 40 qualifying work quarters under Title II of the Social Security Act. @ Yes (No The state limits eligibility to 7 years for certain non-citizens. C Yes @No

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.

CYes @No

fal 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.

{M@] 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. 1 L01(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)(5) for less than 1 year, except for an individual paroled for prosecution. for deferred inspection or pending removal proceedings:

4. Is anon-citizen who belongs to one of the following classes:

{™] Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively:

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:

ry

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:

ol

Granted an administrative stay of removal under 8 CFR 241;

{M] 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 -

{m) Has been granted employment authorization; or

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

TN: ND-13-0022-MM6 Approval Date: 01/16/14 Effective Date:.01/01/14 J North Dakota S89, Page 2

Page 2 of 3

CMS Medicaid Eligibility

| 6. Has been granted withholding of removal under the Convention Against Torture: | 7. Is achild 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 deterred 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 |

| status and/or present an SSN:

individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration

{fm} Qualified non-citizens subject to the S year waiting period described in 8 U.S.C. 1613; 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).

Cy

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, yather 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 Reporis Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN: ND-13-0022-MM6 Approval Date: 01/16/14 Effective Date: 01/01/14 North Dakota S89, Page 3

Page 3 of 3

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: ND- 13- 0022- MM6 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Superseding Pages Notice (delete if not applicable) 4) Approved SPA Pages TN: ND- 13- 0022- MM6 Approval Date: 01/ 16/ 14 Effective Date: 01/ 01/ 14

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 CMS Region VIII December xx, 2013 Julie Schwab, Medicaid Director Medical Services Division North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505- 0250 RE: North Dakota 9 13- 0022-MM6 Dear Ms. Schwab: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number ( TN) ND- 13- 0022-MM6. With this SPA, the State affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility in accordance to the Affordable Care Act. Please be informed that this State Plan Amendment was approved on January 16, 2014 with an effective date January 1, 2014. We are enclosing the summary page ( formerly CMS 179) and the amended plan page( s). If you have any questions concerning this amendment, please contact Ann Clemens at 303) 844- 2125. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health Operations CC: Maggie Anderson, ND Kathy Rodin, ND

ND.0445. R00. 00 - Jan 01, 2014 Page 1 of 2 State/Territory name: North Dakota Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST-YY-0000 witere ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered ND- 13- 0022 Proposed Effective Date 01/ 01/ 2014 mm/ dd/ yyyy) Federal Statute/ Regulation Citation 42 CFR: 435. 4; 435. 406, 435. 956 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment Affordable Care Act- Medicaid Eligibility State Plans- Bucket 6- Citizenship and Immigration status. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: The Single State Agency is responsible for review and submission of Medicaid State Plan amendments, without review and approval of the Governor's office. Signature of State Agency Official Submitted By: Maggie Anderson Last Revision Date: Jan 8, 2014 Submit Date: Oct 23, 2013 TN: ND- 13-0022- MM6 Approval Date: 01/ 16/ 14 Effective Date: 01/ 01/ 14 North Dakota http:// l 57. 199. 113. 99/ MMDL/faces/ protected/ mac/ c01/ print/PrintSelector.jsp 01/ 21/ 2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: TN- ND- 13- 0022 North Dakota PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT( IfApplicable): Attachment 2. 6- A, Page 2, TN 92- 010 S89 Non- Financial Eligibility- Citizenship and Non-Citizen Eligibility Attachment 2. 6- A, Page 3, Item 3, Subparagraphs( d) and( e), 08- 003 TN: ND- 13- 0022- MM6 Approval Date: 01/ 16/ 14 Effective Date: 01/ 01/ 14 North Dakota

C. 0cms Medicaid Eligibility AI I I Control NU III bCr 0938- 1 48 01013 Fxpiration date: 10/ 31 ' 2014 Non- Financial Eligibility S Citizenship and Non- Citizen Eligibility 1902( a)( 46)( 13) 8 1,, 1. S.('. 16 11, 1612, 16 13, and 1641 1903( v)( 2),(',) and ( 4) 42 CTR 437. 4 42( FR 435, 406 42( JAZ 435, 956 Citizenship and Non- Citizen Eligibility The state provides. Medicaid to citizens and nationals of the[; sited States and certain non- citizens consistent with requirements of•T2 CFR 435. 406, including during a reasonable opportunity period pending verification of their citizenship. national status or satisfactory immigration status. The state provides Medicaid eliLdkilitv to otlierwise eligible individuals: N" ho are citi/ ens or nationals of the (_!sited States, and Who are qualified non- citizens as defined in section 43, 1 of the Personal Responsibility and Work Opportunity Fm_] Reconciliation Act ( PRWORA)( 8 ( T. S. C. § 1641), or whose Cligibilitv, is required by section 402( b) of 1TWORA ( 8 ( J. S.(,. 1612( b)) and is not prohibited by section 403 of PRWOR.A ( 8 U. S. C. § 1613); and Who have declared themselves to be citizens or nationals oftlic t''nited States, or an individual having sasatisfactory isfactor jinmigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or satisfactory immigration status consistent with requirements of 1903( x), 1 137( d), 1902( ee) of the SSA and 42 CPR 435. 406, and 956. The reasonable opportunity period begins on and extends 90 clays from the date the notice ol' reasonable opportunity is received by the individual. The ages cN 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 tune to complete the verification process. Yes C 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. es o The date benefits are furnished is: r The date of application containing the declaration of citizenship or immigration status. z z The( late the reasonable opportunity notice is sent. a- Other( late, as described: T c€ti/ enship or lie first day Of' 111C month of the application containing the ation of io T..I..igration status, TN: ND- 13- 0022- MM6 Approval Date: 01/ 16/ 14 Effective Date: 01/ 01/ 14 North Dakota S89, Page l llau,e I ot",

Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non- Citizens whose eligibility is not prohibited by section 403 orPRAVORA 8 U. S. C. t 161 3). C Yes (- 0 No Indicate which requirements apply: The State ITCIUircs Lawful Permanent Residents to have 40 qualifying work quarters Under Title 11 of the Social Security Act. W Yes No The state limits eligibility to 7 years for certain non- citizens. C Yes J` No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 211 and pregnant women, lawfully residing in the United States, as provided in section 1903( v)( 4) of the Act. Yes rW No An individual is considered to he lawfully residing in the L: n iled States i r lie or she is lawfully present and otherwise Ineets the eligibility requirements in the state plan. An individual is considered to be lawfully present in the United States if he or she: I. Is a qualified non-citizen as defined in 8 U. S. C. 164 1( b) and( c); 2. Is a non- citizen in a valid nonimmigrant Status, as defined in 8 U. S. C. 1 10 I( a)( 15) or otherwise under the immigration laws( as defined in 8 U. S. C. 1101( a)( 17)); 3. Is a non- citizen who has been paroled into the (.; Wiled States in accordance with 8 U. S. C. I I 82( d)( 5) for less than I year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings 4. is a non- citizen who belongs to one or the following classes: E:] Granted temporary resident status in accordance with 8 U. S. C. 1160 or I 255a, respectively- Granted Temporary Protected Status( TPS) in accordance with 8 U. S. C. § 1254a. and individuals with pending applications for I PS who have been granted employment authorization: 00 Granted employment authorization under 9 CUR 274a. I 2( c),- Family Unity beneficiaries in accordance with section 301 of Pub. 1.... 101- 649, as amended: Under Deferred Enforced Departure( DEA.)) in accordance with a decision made by the President; Em Granted Deferred Action status, Granted an administrative stay of' removal under 9 CFR 241; Beneficiary of approved visa petition who has a pending application for adliustment of'status, 5. Is an individual with a pending application for asylUrn under 8 U. S. C. 1158, or for withholding of removal under 8 U. S, C. 12', 1, or under the Convention Against Torture who- Has been granted employment authorization-,or Is under the age of 14 and has had an application pending for at least 180 days: TN: ND- 13- 0022- MM6 a FX-e-QU.. J tel-. A/ j qval Date: 01/ 16/ 14 North Dakota S89, Page 2 flai-'e 2 of 3

Medicaid EN0 ibi00ty 6. 1] as bee n granted withho I( I ing of' remova I under the Cori vent ion A gainsi J orture: 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 I_ S. C. I 101( a)( 270) 8. Is lawFully present in '\ merican Samoa under the immigration laws ofAmerican Samoa: or 9. Is a victim ofsevere trafficking in persons, in accordance with the Victims ofJ rafficking and Violence protection Act of 10. Exceptior).: Ali individual vith deferred action under- the Department of Homeland Security' s deterred action for the childhood arrivals process. as described in the Secrctary of Homeland Security' s June 15, 20 12 memorandum. shall not be considered to be lawfully present with respect to any of the above categories in paragraphs I thrOUgh( 9) of this defitlitiojl E] Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition. not relaied to all organ transplant procedure, as defined in I() O',( v)(,) of the SSA and implemented at 42 CFR 440.2is, to the folloNvirn-) individuals who meet all Medicaid eligibility requirements. except documentation ofeitizenship or satistactor inimigration status and/ or present all SSN: On Qualified non- citizens subject to the 5 year- waiting period described in 8 U' S.(_. 16 11, Nori- qualified non- citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with I 903( v)( 4) and im plemented at 43 5. 406( b). According to the Paperwork RedUCtiOn Act of 1 995, no persons are required to respond to a collection ofin formalion unless it dispkqs a valid OMB oon/ m| number. The vn| idONR control number for this infbnomiou co)| cu/ iou bO93X'| 148, Thu time required* complete this information co|) coiuo is estimated to average 40 hours per response, including the time to v: vicn inmmuion,, scmzh c, iuiogdmo resources, Lathcr the data needed, and complete and review the information collection. | f you have comments concerning the accuracy of the time cstirnate( s) or suggestions for improving this form. please write to: CIMS, 7500 Securit,\ Boulevard. Attn: PRA Repons Clearance Officer, Mail Stop[ 4- 26' O5` Baltimore, Maryland ll244 1850. TN: wo' 13' 0022- wm6 Approval Date: 01/ 16n4 Effective Date: 01m1/ 14 North Dakota sos, Page pouc3of3

i Table of Contents State/Territor-y Name: North Dakota State Plan Amendment (SPA) 4: ND-:14- 001 This file contains the following documents,in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Approved SPA,Pages TN: ND- 14- 001 Approval Date: 06/ 17/ 2014 FffectiveDate 01/ 01/ 201-4

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& MedicaidServices 1600 Broadwav,.Suite 700 Denver, CO- 80202 4967 ORMIDICARE&, 11EOICAIO 4TVI FS Region VIII June 17, 2014 Julie.Schwab, Medicaid Director Medical Services Division North Dakota Department of Human Services 600 East Boulevard Avenue;,Dept. 325 Bismarck, ND 58505- 0250 RE: North Dakota 414- 001 Dear Ms. Schwab: We have reviewed the proposed State, Plan Amendment( SPA) submitted under transmittal number (TN) 14- 001. This amendment-allows,the state.agency to conduct presumptive. eligibility for individuals applying for coverage prior to 1/ 1/ 14 and who needed coverage approved effective January 1, to ensure they had' coverage iwplace. Please be informed that this State Plan Amendment is approved effective January 1, 2014. We are enclosing the CMS- 179 and the_:amended plan page( s). If you have any questions,concerning this amendment, please contact Ann Clemens at 303) 844-2125. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health Operations CC: Maggie Anderson, ND Kathy Rodin, ND

DEPARTMENT OF HEALTH AND IIUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB N0, 0938- 0193 TRANSMITTAL AND NOTICE;OF APPROVAL OF I. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 14- 001 North Dakota FOR:, HEALTHCARE FINANCING, ADMINISTRATION 3. PROGRAM IDENTIFICATION: TITLE'XIX OF THE SOCIAL SECURITY ACT MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES January 1, 2014 5. TYPE OF PLAN MATERIAL( Check One):' NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU: I O' IF THISAS AN AMENDMEND(Se arale, TMnsmitia! or each amendment) 6. FEDERAL STATUTEIREGULATION:CITATION:. 7. FEDERAL, BUDGETIMPACT: 42 CFR 435. 1102 and 1103, a. FEY 2014 0 b. FFY 2015 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGENUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IfApplicable): Presumptive Eligibility T1 New 10. SUBJECT OF AMENDMENT: To allow the state agency-to conduct prestimptive eligibility for-a limited period of time. 1'I. GOVERNOR' S REVIEW ( Check One):, GOVERNOR' S OFFICE REPORTED N(Y.COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S: OFFICE' ENCLOSED Delegated to Single State Medicaid agency NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF TATE AGENCY OFFICIAL: 16: RETURN TO`. 13. TYPED NAME: Maggie D. Anderson, Executive Director Maggie D. Anderson ND Department of Human Services 14. TITLE: 600 East.Boulevard avenue Dept 325 Executive Director, ND De t.,oflIuman,Services BismarckND+58505-0250 15. DATE SUBMITTED: March 21, 2014 EORtREGTONAI; OFFICEUSEONLY- 17; DATE RECEIVED IS DATE`APP120VEp March`21, 201A June 17, 2014 rr APPROVED— ONE COPY. - ACHED 19: EFFECTIVE DATE OFanuary1,. 20E AL SIG OF„ GI L OFFICIAL: 21: TYPEDNAME.,. 22 TITLE` ARA D Richard'-C'. Allen MCHO 23. REMARKS ' CL FORM HCFA=179( 07- 92)

Medicaid Eligibility 1 Ne filjl MCI" "a' 'PrIbIR State: North Dakota Transmittaf Number: 14- 001 Notwithstanding the presumptive eligibility elections on the K5, S28, S30, S32. and S33 pages of the state plans the state provides Medicaid coverage to the following groups when,cleterinined presumptively eligible consistent with 42 CFR 435. 1102' and 1103: IF] Children under age 19 El Parents and other caretaker relatives described in 42 CFR:4.35. 1 10 XI Individuals who meet the categorical requirements of 42 CFR 435. 119 E Former foster care children,clescribed in 42 CFR 435. 150 171 Pregnant women described in 42 CFR 435. 116( coverage for pregnant women is limited to ambulatory prenatal care, a's-described in 42 CFR 4351103) The state Medicaid agency is the,qualified entity authorized to determine'eligibility presumptively for these groups. This state plan amendment is forpresumptive, eligibility determ inations,,forcoverage effective on January 1, 2014, for the month of January 2014. The presumptive period begins on the date the presumptive eligibility determination is irlacle. The end date ofthe presumptive period is: The date the eligibility determination for regular Medicaid is made:jfian application for Medicaid is filed by thelast day of the month following the month in which the determination of presumptive eligibility is made. Periods of presumptive cligibi,fity are limited to no more than one period, pencalenclar year. Fhe preSLiniptive, cligibility determination is, based on the,following factors: The individual Must meet the categorical requirements of 42 CFR 435. 110, 435. 116, 435. 118, 435. 119 or 435: 150 Gross income or a reasonable estimate of household income Must not exceed the applicable income standard for the categorical group E Attested state residency 9) Attested citizenship, status as a national, or satisfactory immigration status TN: NO- 14- 001 Approval Date: June 17, 2014 Effective Date: January 1, 2014

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: ND- 14- 0009-MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Approved SPA Pages TN: ND- 14- 0009-MM7 Approval Date: 03/ 24/2017 Effective Date 02/ 01/ 2016

DEPARTMENT OF HEALTH & HUMAN SERVICES s Centers for Medicare & Medicaid Services 1% 1 Stout Street, Room 08- 148 Denver, CO 80294 CENTERS FOR MEDICARE& MEDICAID SERVICES Region VIII March 27, 2017 Maggie Anderson, Acting Medicaid Director Division of Medical Services North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505- 0250 RE: North Dakota# 14- 0009- MM7 Dear Ms. Anderson: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number ( TN) 14- 0009- MM7. This amendment would allow would allow for the implementation of hospital presumptive eligibility and associated claiming of FFP in North Dakota Medicaid. Please be informed that this State Plan Amendment was approved March 24, 2017 with an effective date of February 1, 2016. We are enclosing the CMS- 179 and the amended plan page( s). If you have any questions concerning this amendment, please contact Kirstin Michel at 303) 844- 7036. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations

Medicaid State Plan Eligibility: Summary Page (CMS 179) State/Territory name: North Dakota Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST-YY-0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered. 14- 0009 Proposed Effective Date 02/ 01/ 2016 ( mm/ dd/ YYYY) Federal Statute/Regulation Citation 42 CFR 435. 1100 Federal Budget Impact Federal Fiscal Year Amount First Year 2016 0. 00 Second Year 2017 0. 00 Subject of Amendment Hospital Presumptive Eligibility Governor' s Office Review Governor' s office reported no comment U Comments of Governor' s office received Describe: 2 No reply received within 45 days of submittal Other, as specified Describe: The Department of Human Services is the Single State Medicaid Agency and is delegated to submit State Plan Amendments. Signature of State Agency Official Submitted By: Maggie Anderson Last Revision Date: Mar 1, 2017 Submit Date: Mar 28, 2014 ND- 14- 0009- M M7 Approval Date: 03/ 24/ 2017 Effective Date: 2/ 1/ 2016

IRIS Medicaid Eligibility State Name: North Dakota OMB Control Number: 0938- 1148 Transmittal Number: ND - 14- 0009 Expiration date: 10/ 31/ 2014 3 fir r , zw x E Z a s 42 CFR 435. 1110 One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435. 1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. Yes C` No The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: A qualified hospital is a hospital that: Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of i its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance i with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. Assists individuals in completing and submitting the full application and understanding any documentation requirements. Yes C` No El The eligibility groups or populations for which hospitals determine eligibility presumptively are: Pregnant Women Infants and Children under Age 19 Parents and Other Caretaker Relatives El Adult Group, if covered by the state i Individuals above 133% FPL under Age 65, if covered by the state 0 Individuals Eligible for Family Planning Services, if covered by the state 0 Former Foster Care Children Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state Other Family/Adult groups: Eligibility groups for individuals age 65 and over Eligibility groups for individuals who are blind Eligibility groups for individuals with disabilities Other Medicaid state plan eligibility groups Demonstration populations covered under section 1115 ND- 14-0009- MM7 Approval Date: 3/ 24/ 2017 Effective Date: 2/ 1/ 2016

Medicaid Eligibility The state establishes standards for qualified hospitals making presumptive eligibility determinations. Yes (` No Select one or both: 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. Description of standards: Ninety percent( 90%) of individuals determined eligible for HPE coverage submit a' Full Application' during the HPE period. The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the C submission of an application before the end of the presumptive eligibility period. Eighty-five percent( 85%) of individuals' approved for HPE who submitted a' Full Application' Description of standards: during their HPE period were subsequently determined eligible for Medicaid based on the ' Full Application'. The presumptive period begins on the date the determination is made. The end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, ifno application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: 1 No more than one period within a calendar year. C No more than one period within two calendar years. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. Yes (` No 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. uec ND- 14-0009- MM7 Approval Date: 3/ 24/ 2017 Effective Date: 2/ 1/ 2016

150 Medicaid Eligibility E] The presumptive eligibility determination is based on the following factors: The individual' s categorical or non- financial eligibility for the group for which the individual' s presumptive eligibility is being determined( e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) ro Household income must not exceed the applicable income standard for the group for which the individual' s presumptive eMj eligibility is being determined, if an income standard is applicable for this group. i4 State residency Citizenship, status as a national, or satisfactory immigration status rn 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. r ate.;a` 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 ND- 14-0009- MM7 Approval Date: 3/ 24/ 2017 Effective Date: 2/ 1/ 2016

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: ND- 14- 0102-MM This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Approved SPA Pages TN: ND- 14- 0102- MM Approval Date: 12/ 16/ 2014 Effective Date 1 0/ 01/ 2014

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services Mwmlfth M IS 1600 Broadway, Suite 700 Denver, CO 80202-4967 Cf 7i FOR WOK ART W4K,+, 1t7 SMKf Region VIII December 16, 2014 Julie Schwab, Medicaid Director Medical Services Division North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505- 0250 RE: North Dakota# 14- 0102- MM Dear Ms. Schwab: Enclosed is an approved copy of North Dakota' s state plan amendment ( SPA) 14- 0102-MM, which was submitted to CMS on September 16, 2014. This amendment reflects the North Dakota delegating appeals to the Office of Market Place Eligibility Appeals, effective October 1, 2014. This Single State Agency State Plan Amendment (ND- 14- 0102- MM) supersedes ND- 14- 0101- MM. Enclosed is a copy of the following Al-A3 state plan pages and attachments to be incorporated within a separate section at the end of North Dakota' s approved state plan. The enclosure incorporates the following statement into the North Dakota State Plan: Notwithstanding the checked assurance on A3, the single state agency has not entered into an agreement with the Health and Human Services Appeals Entity to conduct Medicaid fair hearings to date, but will enter into a CMS approved agreement as soon as possible." CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this amendment, please contact Ann Clemens at( 303) 844- 2125. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health Operations CC: Maggie Anderson, ND Stacey Koehly, ND

ND.| 279. R0O. 00 - Oct 0h, 20| 4 puue | of Medicaid State Vli!,,,Ibifity: S,,,un1,mar,v JS 1 9 mmte/ ronxv, rnumo: North Dakota Transmittal Number: Please enter the Transmittal Number( m) in theformu, S7- YnuNm^ wmvxr~th~ xm* ob^ mwv/mx. vy~ molastmwuigits«/ the submission year, and 0000~ vfou, digit number with leading zeros. The dashes must also o, entered. ND' 14' 0102 Proposed Effective Date 10/ 06/2014 mm/ uu/ yrxv) Federal Statute/ Regulation Citation 42CPR431. 10 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment Single State Medicaid Agency; Forms Al- A3 Medicaid Administration revised and submitted W reflect North Dakota delegating appeals to the Office of Market Place Eligibility Appeals, effective October 6, 2014. This Single State Medicaid Agency State Plan Amendment(| 4' 0| O2) oopnmodca ND-| 4' O\ O}. Governor' s Office Review Governor' s office reported oocomment Comments of Governor' s office received Describe: No reply received within 45 days ofsubmittal Other, w, specified Describe: State Plan submission responsibility is with the Single State Agency without review ky the Governor's ofxuc. Signature o[ State Agency Official Submitted By: Maggie Anderson Last Revision Date: Dec 1%, 20/ 4 Submit Date: Sep l6, 20l4 wo' 14- 0102_mm Approval Date: 12/ 12/ 14 Effective Date: 7/ 1/ 14 httn-.-// ymx- rnnodiudxvdc. cnn/ MMDL/faccs6`rotcctcd/ muc/ oO|/ phnt/yrintSc| cotor.isp 12/ 16/ 2014

Medicaid Administration State Name: North Dakota WOB Control Number: 0938 11, 48 Transmittal Number: ND - 14- 0102 Expiration( late: 10131! 2014 State Plan Administration Al Designation and Authority 42 CFR 43 Ll 0 Designation and Authority State Name: North Dakota As a condition for receipt of Federal funds Under title XIX of the Social Security Act, the single state agency named below submits the followiniz 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 X1 and XIX of the Act, and all applicable Federal regulations and other official iSSLIanCeS of the Department. Name of e state agency: single Dakota Department Of I fi-irrian Ser, ices I 11- 1. 1- 1. 111. 11. 11- 111. 1.............................. .......... ................................................................................................................................................. ............................................................... Type of'A- ency: Title IV- A Agency Health C Human Resources C Other The above named agency is the single state agency designated to administer or supervise the administration Of the Medicaid prograrn under title XIX of the Social SeCUrit), Act.( All references in this plan to " the Medicaid agency" mean the agency named as the single state agency.) I he state statutory citation for the legal authority under which the single state agency administers the state plan is: North Dakota Century Code ; 0- 06 05. 1 I he single state agency supervises the administration of the state plan by local political subdivisions. rW Yes C No The state statutory citation for the legal authority under\ N,hicfi the agency supervises the administration of the plan on a statewide basis is: F ............. 11- 11111111111- 111111111111----—---------- Dt. C 50- 06- 05. 1 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: 1- 1- 1------- FDT(-O. 2 The certification signed by the state Attorney General identifying the single state agency and citing the le- al authority under which it administers Or supervises administration of the program has been provided. r—_ _.---—---------------- An attachment is submitted. ND- 14-0102- MM Approval Date: 12/ 12/ 14 Effective Date: 7/ 1/ 14

Medicaid Administration The state plan may be administered solely by the single state agency. or some portions may lie 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 C Yes co' No Waivers ol' the single state agency requirement have been granted under authority of the Intergovernmental Cooperation Act of N 1968. The waivers are still in effect. te, Yes C' No Enter the following infortnation for eacb waiver: ke"i'llove ... Date waiver granted( N,1NI/ DD/ YY): F",' if The type o[' responsibility delegated is( check all that apply): E] Determining eligibility Conducting afair hearings Other Name of state agency to NAhich responsibility is delegated: Administrative Hearings LOf 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 set-vices of such agency to be utilized in administration of tile plan: The North Dakota Legislature created an independent office of administrative hearings( OAI 1) to conduct hearings for various slate agencies. OAH conducts all Medicaid fair hearings. The administrative law judge( AL,J) within OAK,their support staff and all of its resources are utilized for this purpose. When the Department ol' Human Services( Department) receives a request for a Medicaid fail- hearing from in individual, it makes a written request to C) A] I for the assignment ofan ALJ to conduct the hearing and issue recommended conclusions ol' law and a recommended order. After the hearing, the recommendations are mailed to both the applicant and the Department. I' lle Department may adopt., niodifv or reject the Al Ys recommended conclusions of' law when it issue,, its final decision. II'the Deplirtment makes changes in the recommended decision, it Must explain its rationale for changes in its final decision. The applicant may then File a request for a rehearing with 0AI I ( to offer additional evidence) or for reconsideration with the Department( alleging legal errors). " I' his is the last level of' the Department' s review. If such a request. is not tiled, or after 1..) epartnicnt rules in such a request, applicant may appeal to the District Court. Either party may appeal the decision of the District Court to the North Dakota Supreme Court. The Department retains oversight of the State Plan and has a process to monitor tile entire appeals process, including the quality and accuracy of the final decisions made by OAl I. DI IS will ensure that every applicant and beneficiary is inf6mied. in writing, ol' the fair licai-im, process and how to contact OAI I and how to obtain information about fair hearings from that agency. ']' lie Department will ensure that O.Al I complies with all federal and state laws. regulations and policies. This process is the same for all Medicaid fair hearings.']' here is no written agreement between the Department and the OAIL ND- 14- 0102- MM Approval Date: 12/ 12/ 14 Effective Date: 7/ 1/ 14 Pace of 6

Medicaid Administration Fhe methods for coordinating responsibilities ainong the a,-I) cricies involved in administration oftlic plan under the alternate organizational arrangement are as follows: The niethods ofcoordinating responsibilities between the Medicaid Agency and OAl I Ibr conducting fair hearill- s are codified ill state statutes an(] administrative repulaLions. See N. D.C. C. Chapter 54- 57( Office of.Administrative I learim-,$)all(] Chapter 28- 32( Administrative Agencies practice Act). See also, NA.). Administrative Code Title 75- 0 1- 03 ( Dcpdrtment of'[ lunian Services,'Appeals and I learings) and Fille 98( Office ofAdministrative Add F I'lle af-yency that administers Or Supervises the administration of the plan Under Title X of the Act as of.janUary 1, IW, has been separately designated to administer or supervise the achninistrition of that portion of this plan related to blind individuals. The entily or entities that have responsibility f6r determinations of eligibility for families, adults, and f6l_individuals Under 21 are: The Medicaid agency Sin- le state a- enCV Under Title IV- A( in the 50 states or the District of Columbia) or Under Title I or XVI ( AABD) in Guarn Puerto Rico, or the Virgin Islands Ail Exchange that is a government agency established under sections 13 11( b)( I) or 132 1( c)( I) ofthe Affordable(" are Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: Z I lie Medicaid agency Sin- le state a- encv under'[ itle IV- A ( in the 50 states or the District ofColunibia) 01' Undel'' I itlC I or XVI ( AABD) in GUM, Puerto Rico, or the Virgin Islands An Fxchange that is a government agency established under sections 13 11( b)( I) or 1321( c)( I) ofthe A ffi)rdable Care Act E] Fhe Federal agency adminktering the SSI program The entitv or entities that have responsibility for conducting fair hearinos Nkith respect to denials of eligibility based on the applicable modified adJusted aross income standard are: Z Medicaid agency F] Ali Exchange that is a- overninent agency established under sections 13 11( b)( I) or 13-11( c)( I) of the Affordable Care Act An Exchange appeals entity, including all entity established under section 1411( t) ofthe A ff6rdable Care Act Name of entity: 1-1—fell-111i and I lUrnan Services Appeals Entity Fhe agency has established a revie%, process whereby the agency reviews appeals decisions rnadc by the E'xcliange or l"Achange appeals entitv or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies. Yes C No State Plan Administration A2 Organization and Administration 42 CFR 43 1. 10 ND- 14- 0102- MM Approval Date: 12n2M* Effective Date: 7no4 Pxm , of6

Medicaid Administration Organization and Adminish•ation Provide a description of the organization and functions of the Mcdicaid agency. The Department of I lurnan Services Provides services that help vulnerable North Dakotans of all ages to maintain or enhance their L, quality of life, which may be threatened by lack of financial resources, emotional crises, disabling, conditions, or an inability to protect themselves. The Medical Services Division of the Department is responsible lorthe administration of the N'ledicaid and Children' s Health Insurance Program. The Division contains several divisions including utilization revievy, manage care, rate setting, home and coin in un ity- based services, program integrity, eligibility policy, and administrative support. Eligibility determinations are complete(] by the county social service offices, and some eligibility determinations( both Medicaid and CHIP) are completed within the Division.,as part of the Children' s health Insurance Program unit, The Medical Services Division has staff that are responsible for eligibility determinations for the Children's Health Insurance Program. The Department receives the applications directly from families, or sometimes from other entities that are hosting enrollment events where they assist families in completing the applications. Families have the option to send applications directly to our office or to the local county office. Because eligibility must be tested for Medicaid, prior to testino for these staff may make a Medicaid determination. as pan off the process. The Division retains responsibility for establishing policy, training countv, eligibility workers, and providing technical assistance and oversi- lit. The recommended decisions from the Office of Administrative Hearings are received by the Legal Advisory ; nit and reviewed with Division program staff. The Legal Advisory Unit reports to the Executive Director. The final findings ndings aj e reviewed and signed by the Executive Director, Financial support is provided by the Fiscal Administrative Services ir Division, including assisting the Division in developing and monitoring the budget and expenditures and filing the leqLI ed Medicaid and CHIP financial reports. Legal advisory Support is provided by the Legal Advisory Unit including oversight of the appeals process, trust review, and legal guidance on program issues. The Children and Family Services Division oversees all ofthe Child Welfare programs and collaborates with the Division on medical services for foster care children, Such as rehabilitation, i targeted case management and psychiatric residential treatment facility services, The Mental Health and Substance Abuse Services Division provides the policy leadership and is the licensing authority for mental health and substance abuse programs. The Developmental Disabilities Division oversees the Intermediate Care Facility services and the 19 1 5( c) waiver lot- individuals with a Developmental Disability. Upload an organizational chart of the Mcdicaid 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. Medicaid is part of the Department of I luman Services. The Executive Director of the Department is appointed by the Governor. Separate from the Department ofHuman Services, the State Health Officer is the head of the Health Department alit] is also appointed by the Governor. I here are seventeen agency heads that are appointed by the Governor, and serve on his/ her Cabinet. The Fair I learitws occur tividiin the Office of Administrative I learings, which is an executive branch agency that provides independent administrative law judges to preside at administrative hearings. The Director of the Office ol' Administrative I learings is appointed by the Governor, and confirmed by the North Dakota Senate. Entities that determine eligibility other than the Medicaid Agency( if entities arc described under Designation and Authority) Remove ve Type of entity that determines eligibility: C 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)( I) or 1; 321( c)( 1) of the Affordable Care Act C The Federal agency administering the SSI program ND- 14- 0102—MM Approval Date: 12/ 12/ 14 Effective Date: 7/ 1/ 14 Pane 4 of

Medicaid Administration Provide a description of the staff designated by the entity and the Functions they pe•lorin in carrying out their responsibility. the Federally- Facilitated Marketplace( FFN/I) will be determining eligibility for Medicaid for groups of individuals whose income eligibility is determined based on MAGI income methodology and who apply fill-01,11-111 the IT.M. The FFAM Hill not be assigning all individual who is determined eligible for Medicaid whose income eligibility is determined using MAGI niethodo1cwy to a, specific eligibility group, determining cost- sharing( if applicable), or assigning a benefit package; these are functions that will be performed by the single state agency. 1. 11111- 1. 1....................... ...............:..................................................--................................--................................................................................ ........................................................................................ ........................................--...............................................................-............... Add Entities that conduct fair hearings other than the Medicaid APNney ( if are described under Designation and Authority) EKern=0c Type of entity that conducts fair hearings: C An Exchange that is a government agency established under sections 131 l( b)( I) or 1321( c)( I) of the Affordable Care Act W 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. The HHS Appeals Entity will conduct Medicaid fair hearings for individuals whose Medicaid eligibility has been determined and found ineligible for Medicaid by the Federally- facilitated ;Marketplace( FTM). I' llese will be individuals whose income eligibility is determined based on MAGI incolTIC methodology and who applied for health coverage through the FFN1 1.-_-] 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 (—o No The types of the local Subdivisions that administer the state plan under the supervision of the Medicaid agency are: Counties C Parishes C Other Are all of the local subdivisions indicated above used to administer the state plan? 6 Yes (' No Indicate the number used to administer the state plan: 47 Description of the staff and functions of the local subdivisions: ic" of til7 Counties make eligibility determinations for all Medicaid populations. Eligibility determination responsibilities are ,,several county social service offices are outlined in North Dakota Century Code 50- 01. 2- 03. 2 and 50- 01. 2- 00. 1 1 lie sc areas of the state where the county social service boards combined for efficiencies. When there is ll con olid tio , the county social service boards in the individual counties no longer exist, and rather one county, social service board was created to oversee the county social service operations of the multi- county area. The Medicaid eligibility area( county eligibility workers) are part of the operations Under the authority of the county social service board. Medicaid fail- hearings may be held at the county office( the location), but the hearing is conducted by the Office of Administrative Hearings. ND- 14-0102—MM Approval Date: 12/ 12/ 14 Effective Date: 7/ 11/ 14 Pas-,e 5 of

Medicaid .Administration State Plan Administration Assurances A3 42 CFR 43 1. 10 42 CFR 43 1, 12 42 CFR 43 1 50 Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements ol' 42 CFR 43 1 50. All requirements of 42 CTR 43 1. 10 are inct. I here is a Medical Care Advisory Committee to the agency director oil health and medical services established in accordance with niectin2 all the requirements ol' 42 CFR 43 1. 12. encv does not delcuate, to other than its own officials, the authority to supervise the plan oi- to develop or issue policies, rules. and regulations oil prograrn inatters. Assurance for states that have delegated authority to determine eligibility: There is a written aoreernent between the Medicaid agency and the Exchange or any other state or local agency that has been delei_,ated authority to determine eli- ibility forkledicaid eligibility in compliance with 42 CFR 43 1. 10( 4 Assurances for states that have delegated authorilv to conduct I' air hearings: There is a written agreement betv,cen the Medicaid agency and the Fxchange or Fxchange appeals entily that has been delegated Iauthority to conduct Medicaid fair hearings in cornplizance with 42( TR 43 1. 1 O( d). When aLll:horiiv is delegated to the Exchange or ail Fxchange appeals entity, individuals who have requested a lair hearin- are given the option to ll'ave their fair hearing conducted instead by the Medicaid agcnc Assurance for states that have delegated authority to determine eligibility and/ or to conduct fair hearings: I he Medicaid a,-Tency does not delegate authority to make eligibility detcrin i nat ions oi- to conduct lair hcarim,,s to entities other[ hall RV ovenirrient aacncics which maintain personnel standards oil a Merit basis. According m the paperwork Reduction Act of 1995, no persons are required to respond to a collection ofinforination unless it displays a valid OMB control number. The valid ONID control number for this iofonnu| ion collection isU9] 8-\ | 4X. The time required mcomplete this ink`nnmioo cuUeuim, iscsbnimcd m average 4O hours per response. including the dmc* review instructions. xcxoh existing data resources, gather the data needed, and complete and review the information collection. | f You have comments concerning the accuracy o/ the/ imecgimatc( wo, suggestions for improving this k/un, please write to: CMS, 7500 Security Bnv| rvnx1, Attn: PRA Reports Clearance Officer, Mail Stop C4' 26- 05. Baltimore, Maryland 2| 244- lX50, vzo/ 4| ao3 mo' 14-0102_ Mm Approval Date: 12/ 12/ 14 Effective Date: 7n/ 14

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Attachjt6nt 1. 1- A MEDICAL . ASSISTANCE PROGR M State of North. Dakota OCT ATMRNEY GS ' R L S CERTIFICATION I certify that: The North Dakota Department of Human Services is the single State agency responsible for: administering the plan. The legal authority under which the agency administers the plan on a Statewide basis is statutory citation) supervising the administration of the plan by local political subdivisions. The Legal authority under which the agency supervises the administration of the plan on a Statewide basis is contained in 50- 06- 05. 1 NDCC statutory citation) The agency' s legal authority to make rules and regulations that are binding on the political subdivisions administer- ing the plan is 50. 24. 1- 04 NDCC statutory citation) August 5, 1982 DATE Signature- Attorney Gene=ral 7 Title r 7 cat j l< t t t1 t- '`

MEDICAID ADMINISTRATION TRANSMITTAL NUMBER: STATE: 14- 01022- MM North Dakota Notwithstanding the checked assurance on A3. the single state agency has not. entered into an agreement with the Health and I luman Services Appeals Entity to conduct Medicaid fair hearings to date, but will enter into a CMS- approved agreement as soon as possible. ND- 14- 0102—MM Approval Date: 12/ 12/ 14 Effective Date: 7/ 1/ 14 FORN4 I 1CFA- 1 79( 07- 92)

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: ND -15- 0020 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179 -like data) 3) Approved SPA Pages TN: ND -15- 0020 Approval Date: 03/ 15/ 2016 Effective Date 10/ 05/ 2015

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1961 Stout Street, Room 08- 148 Denver, CO 80294 Region VIII CENTERS FOR MEDICARE & MEDICAID SERVICES March 15, 2016 Maggie Anderson, Acting Medicaid Director Division of Medical Services North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505- 0250 RE: North Dakota # 15- 0020 Dear Ms. Anderson: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number ( TN) 15- 0020. This amendment allows the state to add the Medicaid Expansion enrollees, who have been determined Medically Frail, and who have chosen the Traditional Medicaid coverage, to the list of groups who are exempt from mandatory enrollment in the PCCM program. This amendment also exempts inmates receiving inpatient services from mandatory enrollment in the PCCM program, and adds Pregnant Women who are eligible for the Medicaid Expansion and have chosen Traditional Medicaid coverage to the list of groups that will be enrolled in the PCCM program on a mandatory basis. Please be informed that this State Plan Amendment was approved March 15, 2016 with an effective date of October 5, 2015. We are enclosing the CMS -179 and the amended plan page( s). If you have any questions concerning this amendment, please contact Kirstin Michel at 303) 844- 7036. Sincerel , Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations cc: Maggie Anderson, ND Kathy Rodin, ND

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES 1 TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): I. TRANSMITTAL NUMBER: 15-0020 FORM APPROVED OMB NO. 093$- 0193 2. STATE North Dakota 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAID) 4. PROPOSED EFFECTIVE DATE October 5, 2015 NEW STATE PLAN [] AMENDMENT TO BE CONSIDERED AS NEW PLAN COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AM 6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 438 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: ATTACHMENT 3. 1- F, Pages 1- 11 10. SUBJECT OF AMENDMENT: Amends the North Dakota State Plan to add the Medicaid Expansion enrollees, who have been determined Medically Frail, and who have chosen the Traditional Medicaid coverage, to the list of groups who are exempt from mandatory enrollment in the PCCM program. This amendment also exempts inmates receiving inpatient services from mandatory enrollment in the PCCM program, and adds Pregnant Women who are eligible for the Medicaid Expansion and have chosen Traditional Medicaid coverage to the list of groups that will be enrolled in the PCCM program on a mandatory basis. 1L GOVERNOR' S REVIEW (Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT Q COMMENTS OF GOVERNOR' S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL AMENDMENT ENDMENT (Separate Transmittalfor each amendment) 7. FEDERAL BUDGET IMPACT: a. FFY 2016 S no fiscal impact expected b. FFY 2017 $ no fiscal impact expected 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (lfApplicable): ATTACHMENT 2.1- A, Pages 1- 11 12. SIGNAT 13. TYPE OTHER, AS SPECIFIED: Maggie D. Anderson, Executive Director, Department of Human Services 14. TITLE: Executive Director, Department of Human Services 15. DATE SUBMITTED: December 22, 2015 Revised 3- 10-2016 Maggie D. Anderson IfEC 16. RETURN TO: Maggie D. Anderson, Executive Director ND Department of Human Services 600 East Boulevard Avenue Dept 325 Bismarck ND 58505-0250 REOONN4,0rFICEUSE Q. ATE`APPRO N`APPROVED .. i COP:_ 4 GIIED.: a ch FORM CMS -179 ( 07-92)

CMS -PM -10120 Date: March 2016 State: North Dakota ATTACHMENT 3. 1- F Page 1 OMB No.: 0938- 0933 Citation Condition or Requirement 1932( a)( 1)( A) A. Section 1932( a)( 1)( A) of the Social Security Act. The State of North Dakota enrolls Medicaid beneficiaries on a mandatory basis into managed care entities ( managed care organization (MCOs) and/ or primary care case managers ( PCCMs)) in the absence of section 1115 or section 1915( b) waiver authority. This authority is granted under section 1932( a)( 1)( A) of the Social Security Act (the Act). Under this authority, a state can amend its Medicaid state plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without being out of compliance with provisions of section 1902 of the Act on state wideness ( 42 CFR 431. 50), freedom of choice ( 42 CFR 431. 51) or comparability (42 CFR 440.230). This authority may not be used to mandate enrollment in Prepaid Inpatient Health Plans ( PIHPs), Prepaid Ambulatory Health Plans (PAHPs), nor can it be used to mandate the enrollment of Medicaid beneficiaries described in 42 CFR 438. 50( d). Where the state' s assurance is requested in this document for compliance with a particular requirement of 42 CFR 438 et seq., the state shall place check mark to affirm such compliance. 1932( a)( 1)( B)( i) B. Managed Care Delivery System. 1932( a)( 1)( B)( ii) 42 CFR 438. 50( b)( 1)-( 2) The State will contract with the entity(ies) below and reimburse them as noted under each entity type. 1. ElMCO a. Capitation 2. NPCCM (individual practitioners) a. N Case management fee b. Bonus/incentive payments c. Other (please explain below) 3. NPCCM (entity based) a. N Case management fee b. Bonus/incentive payments c. Other (please explain below) For states that elect to pay a PCCM a bonus/incentive payment as indicated in B. 2.b. or B. 3. b, place a check mark to affirm the state has met all of the TN No. 15- 0020 Supersedes Approval Date March 15, 2016 Effective Date October 5, 2015 TN No. 09- 025

CMS -PM -10120 Date: March 2016 State: North Dakota ATTACHMENT 3. 1- F Page 2 OMB No.: 0938- 0933 Citation Condition or Requirement following conditions (which are representative of the risk incentive rules for managed care contracts published in 42 CFR 438. 6( c)( 5)( iv)). a. Incentive payments to the PCCM will not exceed 5% of the total FFS payments for those services provided or authorized by the PCCM for the period covered. b. Incentives will be based upon a fixed period of time. c. Incentives will not be renewed automatically. d.Incentives will be made available to both public and private PCCMs. e. Incentives will not be conditioned on intergovernmental transfer agreements. f. Incentives will be based upon specific activities and targets. CFR 438. 50( b)( 4) C. Public Process. Describe the public process including tribal consultation, if applicable, utilized for both the design of the program and its initial implementation. In addition, describe what methods the state will use to ensure ongoing public involvement once the state plan program has been implemented. ( Example: public meeting, advisory groups.) The design of the program is to allow Medicaid enrollees to select a Primary Care Provider (PCP) to provide, through an ongoing patient/provider relationship, primary care services and referral for all necessary services. The State will consult with the Medicaid Medical Advisory Committee and the Department of Human Services/Tribal Health/Indian Health Services Committee to ensure on-going public involvement. The North Dakota Medicaid Medical Advisory Committee and the Department of Human Services/ Tribal Health/ Indian Health Services committee meet three to four times per year. The State reports to both committees on program changes. In addition, the state seeks the input of the committee on program changes and implementation options. TN No. 15- 0020 Supersedes Approval Date March 15, 2016 Effective Date October 5, 2015 TN No. 09- 025

CMS -PM -10120 Date: March 2016 State: North Dakota ATTACHMENT 3. 1- F Page 3 OMB No.: 0938- 0933 Citation Condition or Requirement 1932( a)( 1)( A)(i)(I) 1903( m) 42 CFR 438. 50( c)( 1) 1932( a)( 1)( A)(i)(I) 1905( t) 42 CFR 438. 50( c)( 2) 1902( a)( 23)( A) D. State Assurances and Compliance with the Statute and Regulations. If applicable to the state plan, place a check mark to affirm that compliance with the following statutes and regulations will be met. 1. El The state assures that all of the applicable requirements of section 1903( m) of the Act, for MCOs and MCO contracts will be met. 2. NThe state assures that all the applicable requirements of section 1905( t) of the Act for PCCMs and PCCM contracts will be met. 1932( a)( 1)( A) 3. NThe state assures that all the applicable requirements of section 1932 42 CFR 438. 50( c)( 3) ( including subpart ( a)( 1)( A)) of the Act, for the state' s option to limit freedom of choice by requiring Beneficiaries to receive their benefits through managed care entities will be met. 1932( a)( 1)( A) 4. NThe state assures that all the applicable requirements of 42 CFR 431. 51 42 CFR 431. 51 regarding freedom of choice for family planning services and supplies as 1905( a)( 4)( C) defined in section 1905( a)( 4)( C) will be met. 1932( a)( 1)( A) 5. NThe state assures that it appropriately identifies individuals in the mandatory exempt groups identified in 1932( a)( 1)( A)(i). 1932( a)( 1)( A) 42 CFR 438 1903( m) 1932( a)( 1)( A) 42 CFR 438. 6( c) 42 CFR 438. 50( c)( 6) 1932( a)( 1)( A) CFR 447. 362 42 CFR 438. 50( c)( 6) 6. NThe state assures that all applicable managed care requirements of 42 CFR Part 438 for MCOs and PCCMs will be met. 7. El The state assures that all applicable requirements of 42 CFR 438. 6( c) for payments under any risk contracts will be met. 8. El The state assures that all applicable requirements of 42 CFR 447.362 for 42 payments under any non -risk contracts will be met. 45 CFR 92.36 9. NThe state assures that all applicable requirements of 45 CFR 92.36 for procurement of contracts will be met. TN No. 15- 0020 Supersedes Approval Date March 15, 2016 Effective Date October 5, 2015 TN No. 09- 025

CMS -PM -10120 Date: March 2016 State: North Dakota ATTACHMENT 3. 1- F Page 4 OMB No.: 0938- 0933 Citation Condition or Requirement 1932( a)( 1)( A) 1932( a)( 2) E. Populations and Geographic Area 1. Included Populations. Please check which eligibility populations are included, if they are enrolled on a mandatory ( M) or voluntary (V) basis, and the geographic scope of enrollment. Under the geography column, please indicate whether the nature of the population' s enrollment is on a statewide basis, or if on less than a statewide basis, please list the applicable counties/regions. Population M Geographic Area V Geographic Area Excluded Section 1931 Children & Related Populations — 1905( a)( i) M Statewide Section 1931 Adults & Related Populations1905( a)(ii) M Statewide Low -Income Adult Group E Former Foster Care Children under age 21 M Statewide Former Foster Care Children age 21- 25 M Statewide Section 1925 Transitional Medicaid age 21 and older M Statewide SSI and SSI related Blind Adults, age 18 or older* - 1905( a)( iv) E Poverty Level Pregnant Women — 1905( a)( viii) M Statewide SSI and SSI related Blind Children, generally under age 18 — 1905( a)( iv) E SSI and SSI related Disabled children under age 18 E SSI and SSI related Disabled adults age 18 and older — 1905( a)( v) E SSI and SSI Related Aged Populations age 65 or older - 1905 (a)( iii) E SSI Related Groups Exempt from Mandatory Managed Care under 1932( a)( 2)( B) E TN No. 15- 0020 Supersedes TN No. 09- 025 Approval Date March 15, 2016 Effective Date October 5, 2015

CMS -PM -10120 Date: March 2016 State: North Dakota ATTACHMENT 3. 1- F Page 5 OMB No.: 0938- 0933 Citation Condition or Requirement Population M Geographic Area V Geographic Area Excluded Recipients Eligible for Medicare E American Indian/Alaskan Natives M Statewide -IHS service facilities serve as Primary Care Providers within the PCCM Program. Children under 19 who are eligible for SSI E Children under 19 who are eligible under Section 1902( e)( 3) E Children under 19 in foster care or other in-home placement This includes adoption assistance. E Children under 19 receiving services funded under section 501( a)( 1)( D) of title V and in accordance with 42 CFR 438. 50(d)( v) E Other: Women' s Way Program Enrollees E Enrollees receiving refugee assistance E Individuals residing in: a Nursing Home/Long Term Care Facility; Swing Bed; Psychiatric Residential Treatment Facility; the State Hospital (Individuals under 21 or over 65) ; Intermediate Care Facility/. E Pregnant Women eligible under Medicaid Expansion, as authorized by the Affordable Care Act, and have selected Traditional Medicaid coverage. M Statewide Inmates receiving inpatient E TN No. 15- 0020 Supersedes TN No. 09- 025 Approval Date March 15, 2016 Effective Date October 5, 2015

CMS -PM -10120 Date: March 2016 State: North Dakota ATTACHMENT 3. 1- F Page 6 OMB No.: 0938- 0933 Citation Condition or Requirement Population M Geographic Area V Geographic Area Excluded services Individuals eligible under Medicaid Expansion, as authorized by the Affordable Care Act, who are inmates receiving inpatient services or who have been determined Medically Frail and have selected Traditional Medicaid coverage. E 1932( a)( 4) 2. Excluded Groups. Within the populations identified above as Mandatory or Voluntary, there may be certain groups of individuals who are excluded from the managed care program. Please indicate if any of the following groups are excluded from participating in the program: Other Insurance --Medicaid beneficiaries who have other health insurance. Reside in Nursing Facility or ICF -Medicaid beneficiaries who reside in Nursing Facilities (NF) or Intermediate Care Facilities (ICF). Enrolled in Another Managed Care Program --Medicaid beneficiaries who are enrolled in another Medicaid managed care program Eligibility Less Than 3 Months --Medicaid beneficiaries who would have less than three months of Medicaid eligibility remaining upon enrollment into the program. Participate in HCBS Waiver --Medicaid beneficiaries who participate in a Home and Community Based Waiver (HCBS, also referred to as a 1915( c) waiver). Retroactive Eligibility—Medicaid beneficiaries for the period of retroactive eligibility. Other (Please define): F. Enrollment Process. 1. Definitions. TN No. 15- 0020 Supersedes Approval Date March 15, 2016 Effective Date October 5, 2015 TN No. 09- 025

CMS -PM -10120 Date: March 2016 State: North Dakota ATTACHMENT 3. 1- F Page 7 OMB No.: 0938- 0933 Citation Condition or Requirement a. Auto Assignment- assignment of a beneficiary to a health plan when the beneficiary has not had an opportunity to select their health plan. b. Default Assignment- assignment of a beneficiary to a health plan when the beneficiary has had an opportunity to select their health plan. 2. Please describe how the state effectuates the enrollment process. Select an enrollment methodology from the following options and describe the elements listed beneath it: a. The applicant is permitted to select a health plan at the time of application. i. How the state fulfills its obligations to provide information as specified in 42 CFR 438. 10( e). ii. What action the state takes if the applicant does not indicate a plan selection on the application. iii. If action includes making a default assignment, describe the algorithm used and how it meets all of the requirements of 42 CFR 438. 50(f). iv. The state' s process for notifying the beneficiary of the default assignment. Example: state generated correspondence.) b. N The beneficiary has an active choice period following the eligibility determination. i. How the beneficiary is notified of their initial choice period, including its duration. A State generated letter is sent to the recipient notifying them of the need to choose a PCP and the time frame which is required to contact the State or designated agent. The letter also contains information regarding the auto -assignment process should a provider not be chosen within the allotted timeframe. If a PCP is auto -assigned, another State generated letter is sent to the recipient notifying them of the assignment. ii. How the state fulfills its obligations to provide information as specified in 42 CFR 438. 10( e). TN No. 15- 0020 Supersedes Approval Date March 15, 2016 Effective Date October 5, 2015 TN No. 09- 025

CMS -PM -10120 Date: March 2016 State: North Dakota ATTACHMENT 3. 1- F Page 8 OMB No.: 0938- 0933 Citation Condition or Requirement This information is provided to members in the Application for Assistance Guidebook. A hardcopy of this Guidebook is given to all members who complete a paper application. The Application for Assistance Guidebook is available on line and the link to the guidebook is in the online application. iii. Describe the algorithm used for default assignment and describe the algorithm used and how it meets all of the requirements of 42 CFR 438. 50(f). For those recipients who have not had a PCP previously assigned or claims history within the past 12 months, the system will take the bottom 50% of PCPs that are available for selection, determine the county each PCP is located in, take the recipients that have not had a PCP assigned and determine which county they are in, create subsets for the recipients for each county along with the PCPs located in that county, randomly auto -assign a PCP to the recipient in that county. The bottom 50% of PCPs subset is recalculated upon generation of the auto -assignment report. iv. The state' s process for notifying the beneficiary of the default assignment. A State generated letter is sent to the recipient upon auto -assignment of a provider and describes the right to disenroll without cause during the first 90 days of their enrollment with the Provider. c. The beneficiary is auto -assigned to a health plan immediately upon being determined eligible. i. How the state fulfills its obligations to provide information as specified in 42 CFR 438. 10( e). ii. The state' s process for notifying the beneficiary of the auto -assignment. Example: state generated correspondence.) iii. Describe the algorithm used for auto -assignment and describe the algorithm used and how it meets all of the requirements of 42 CFR 438. 50(f). TN No. 15- 0020 Supersedes Approval Date March 15, 2016 Effective Date October 5, 2015 TN No. 09- 025

CMS -PM -10120 Date: March 2016 State: North Dakota ATTACHMENT 3. 1- F Page 9 OMB No.: 0938- 0933 Citation Condition or Requirement 1932( a)( 4) 42 CFR 438. 50 3. State assurances on the enrollment process. Place a check mark to affirm the state has met all of the applicable requirements of choice, enrollment, and re -enrollment. a. NThe state assures it has an enrollment system that allows Beneficiaries who are already enrolled to be given priority to continue that enrollment if the MCO or PCCM does not have capacity to accept all who are seeking enrollment under the program. b. NThe state assures that, per the choice requirements in 42 CFR 438.52, Medicaid Beneficiaries enrolled in either an MCO or PCCM model will have a choice of at least two entities unless the area is considered rural as defined in 42 CFR 438. 52( b)( 3). c. The state plan program applies the rural exception to choice requirements of 42 CFR 438. 52( a) for MCOs and PCCMs in accordance with 42 CFR 438. 52( b). Please list the impacted rural counties: NThis provision is not applicable to this 1932 State Plan Amendment. d. N The state applies the automatic reenrollment provision in accordance with 42 CFR 438.56( g) if the recipient is disenrolled solely because he or she loses Medicaid eligibility for a period of 2 months or less. This provision is not applicable to this 1932 State Plan Amendment. 1932( a)( 4) G. Disenrollment. 42 CFR 438. 56 1. The state wi11N/ will not El limit disenrollment for managed care. 2. The disenrollment limitation will apply for six months (up to 12 months). 3. NThe state assures that beneficiary requests for disenrollment (with and without cause) will be permitted in accordance with 42 CFR 438. 56( c). 4. Describe the state' s process for notifying the Medicaid Beneficiaries of their right to disenroll without cause during the first 90 days of their enrollment. (Examples: state generated correspondence, HMO enrollment packets etc.) TN No. 15- 0020 Supersedes Approval Date March 15, 2016 Effective Date October 5, 2015 TN No. 09- 025

CMS -PM -10120 Date: March 2016 State: North Dakota ATTACHMENT 3. 1- F Page 10 OMB No.: 0938- 0933 Citation Condition or Requirement H. 1932( a)( 5)( c) 42 CFR 438. 50 42 CFR 438. 10 1932( a)( 5)( D)( b) 1903( m) 1905( t)(3) A State generated letter is sent to the recipient upon auto -assignment of a provider and describes the right to disenroll without cause during the first 90 days of their enrollment with the Provider. 5. Describe any additional circumstances of "cause" for disenrollment (if any). PCP relocates, PCP disenrolls as a Medicaid provider, PCP disenrolls as a PCP provider, and recipient' s lack of access to a PCP. The State will review disenrollments for medical reasons on an individual basis. Information Requirements for Beneficiaries NThe state assures that its state plan program is in compliance with 42 CFR 438. 10( e) for information requirements specific to MCOs and PCCM programs operated under section 1932( a)( 1)( A)(i) state plan amendments. I. List all benefits for which the MCO is responsible. 1932( a)( 5)( D)( b)( 4) J. 42 CFR 438. 228 1932( a)( 5)( D)( b)( 5) K. 42 CFR 438. 206 42 CFR 438. 207 1932( a)( 5)( D)( c)( 1)( A) L. 42 CFR 438. 240 Medicaid recipients enrolled in PCCM' s have access to all Medicaid services with appropriate referrals. The state assures that each managed care organization has established an internal grievance procedure for enrollees Describe how the state has assured adequate capacity and services. ElThe state assures that a quality assessment and improvement strategy has been developed and implemented. 1932( a)( 5)( D)( c)( 2)( A) M. ElThe state assures that an external independent review conducted by a 42 CFR 438. 350 qualified independent entity will be performed yearly. 1932 ( a)( 1)( A)(ii) N. Selective Contracting Under a 1932 State Plan Option TN No. 15- 0020 Supersedes TN No. 09- 025 Approval Date March 15, 2016 Effective Date October 5, 2015

CMS -PM -10120 Date: March 2016 State: North Dakota ATTACHMENT 3. 1- F Page 11 OMB No.: 0938- 0933 Citation Condition or Requirement To respond to items # 1 and # 2, place a check mark. The third item requires a brief narrative. 1. The state will/ will not© intentionally limit the number of entities it contracts under a 1932 state plan option. 2. ElThe state assures that if it limits the number of contracting entities, this limitation will not substantially impair beneficiary access to services. 3. Describe the criteria the state uses to limit the number of entities it contracts under a 1932 state plan option. ( Example: a limited number ofproviders and/or enrollees.) 4. © The selective contracting provision in not applicable to this state plan. 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- 0933. The time required to complete this information collection is estimated to average 10 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 CMS -10120 ( exp. 3/ 31/ 2014) TN No. 15- 0020 Supersedes Approval Date March 15, 2016 Effective Date October 5, 2015 TN No. 09- 025

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: 17-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages TN: ND- 17- 0008 Approval Date: 11/ 27/2019 Effective Date: 01/ 01/ 2017

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1961 Stout Street, Room 08- 148 Denver, CO 80294 rc ARE& MEDICAID SERVICES Denver Regional Operations Group CENTER FOR MEDICAID& CHIP SERVICES December 2, 2019 Caprice Knapp, Medicaid Director Division of Medical Services North Dakota Department of Human Services 600 E. Boulevard Avenue, Dept. 325 Bismarck, ND 58505- 0250 Dear Ms. Knapp: The Centers for Medicare and Medicaid Services ( CMS) has completed its review of North Dakota State Plan Amendment ( SPA) TN# 17- 0008, which was submitted on March 29, 2017 to eliminate a non-emergency visit to the emergency department copay and to update an office visit copay in the state plan. During the review of this SPA, CMS concluded that the state was not in compliance with the requirements of sections 1916A(a)( 2)( B), ( b)( 1)( 13)( ii) and ( b)( 2)( A) of the Social Security Act the Act), as implemented at 42 CFR §447. 56( f). These statutory and regulatory requirements limit the total amount of premiums and cost sharing to a five percent aggregate cap. The aggregate cap is based on the beneficiary' s family income used to determine eligibility (or, in the case of a family with multiple beneficiaries, all beneficiaries in the household). During the review of the SPA, the state was unable to describe and implement a tracking mechanism that met the regulatory requirements. Therefore, the state elected to submit SPA TN 19- 0016 to eliminate all cost sharing effective October 1, 2019. This SPA will be approved concurrently with SPA TN# 17- 0008. Based upon the information received, we approved SPA# 17- 0008 on November 27, 2019, with an effective date of January 1, 2017. Enclosed is a copy of the CMS- 179 form, as well as the approved pages for incorporation into the North Dakota State Plan. If you have any questions regarding this SPA, please contact Kirstin Michel, by email at Kirstin Michel@cms. hhs.gov or telephone at 303- 844- 7036. Sincerely, Mary Marchioni Acting Deputy Division Director Western Regional Operations Group Denver Regional Office Centers for Medicaid and CHIP Services

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO, 0938- 0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 17- 0008 North Dakota FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES January 1, 2017 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 fbr each amendment) 6. FEDERAL STATUTE/ REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2017 S 1, 780 42 CFR 447.54 & 42 CFR 447.56 b. FFY 2018 S 3,560 8, PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable): Attachment 4. 18- A Page 1 Attachment 4. 18- A Page 1 Attachment 4. 18- A Page Ig - VACATED Attachment 4. 18- A Page 1 g Attachment 4. 18- C Page 1 Attachment 4. 18- C Page 1 Attachment 4. 18- C Page Ig- VACATED Attachment 4. 18- C Page Ig 10. SUBJECT OF AMENDMENT: Amends the State Plan to update the cost sharing for Medicaid enrollees. 11. GOVERNOR' S REVIEW ( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED Mayvie D. Anderson, Director, NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Medical Services Division 12. SIGNATU 16. RETURN TO: 13. TYPE NA E: Maggie D. Anderson, Director Maggie D. Anderson Medical Services Division 14. TITLE: ND Department of Human Services Director, Medical Services Division 600 East Boulevard Avenue Dept 325 15. DATE SUBMITTED: Bismarck ND 58505- 0250 March 29, 2017 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: March 29, 2017 November 27, 2019 PLAN APPROVED- ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: January 1, 2017 21. TYPED NAME: 22. TITLE: Mary Marchioni Acting Deputy Division Director, WROG 23. REMARKS: FORM CMS- 179 ( 07- 92)

TN No. _17-0008______ Approval Date _11/27/2019__ Effective Date __01/01/2017___ Supersedes TN No. _93-14___ CMS ID: 0053C/0061E Attachment 4.18-A Revision: CMS-PM-85-14 (BERC) Page 1 September 1985 OMB.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: _ North Dakota_ _ A. The following charges are imposed on the categorically needy for services other than those provided under section 1905 (a) (1) through (5) and (7) of the Act: Service Type of Charge Deduct. Coins. Copay. Amount and Basis for Determination Office/Consultation Visit X 2.00 per visit * Copayments may be imposed except for as exempted under 42 CFR 447.56. The standard copayment is based on the average payment per physician office visit for the calendar year 1992. The average payment per office visit is $31.72. This average rate allows North Dakota to impose a $2 copayment on all visits in accordance with 42 CFR 447.54 and 55.

TN No. _17-0008___ Approval Date _ __ Effective Date __01/01/2017 _ Supersedes TN No. _00-013___ CMS ID: 0053C/0061E Attachment 4.18-A Revision: CMS-PM-85-14 (BERC) Page 1g September 1985 OMB.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: _ North Dakota_ _ A. The following charges are imposed on the categorically needy for services other than those provided under section 1905 (a) (1) through (5) and (7) of the Act: Service Type of Charge Deduct. Coins. Copay. Amount and Basis for Determination Vacated 11/27/2019

TN No. _17-0008______ Approval Date _11/27/2019 _ Effective Date __01/01/2017___ Supersedes TN No. _93-14___ CMS ID: 0053C/0061E Attachment 4.18-C Revision: CMS-PM-85-14 (BERC) Page 1 September 1985 OMB.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: _ North Dakota_ _ A. The following charges are imposed on the medically needy for services: Service Type of Charge Deduct. Coins. Copay. Amount and Basis for Determination Office/Consultation Visit X 2.00 per visit * Copayments may be imposed except for as exempted under 42 CFR 447.56. The standard copayment is based on the average payment per physician office visit for the calendar year 1992. The average payment per office visit is $31.72. This average rate allows North Dakota to impose a $2 copayment on all visits in accordance with 42 CFR 447.54 and 55.

TN No. _17-0008___ Approval Date _11/27/2019 _ Effective Date __01/01/2017 _ Supersedes TN No. _00-013___ CMS ID: 0053C/0061E Attachment 4.18-C Revision: CMS-PM-85-14 (BERC) Page 1g September 1985 OMB.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: _ North Dakota_ _ A. The following charges are imposed on the medically needy for services: Service Type of Charge Deduct. Coins. Copay. Amount and Basis for Determination Vacated

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: 18-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) 179 4) Approved SPA Pages TN: ND- 18- 0015 Approval Date: 09/ 28/2018 Effective Date: 07/ 01/ 2018

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Denver Regional Office 1961 Stout Street, Room 08-148 Denver, CO 80294 REGION VIII – DENVER October 1, 2018 Maggie Anderson Division of Medical Services North Dakota Department of Human Services 600 East Boulevard Avenue, Department 325 Bismarck, ND 58505-0250 RE: North Dakota #18-0015 Dear Ms. Anderson: We have reviewed the proposed State Plan Amendment (SPA) submitted under transmittal number TN) 18-0015. This amendment adds the eligibility group described at section 1902(a)(10)(A)(ii)(VI) of the Social Security Act and implemented at 42 CFR 435.217 of the regulations to North Dakota Medicaid’s State Plan. The SPA also allows parental resources to be disregarded from consideration in determining eligibility for children under that group. During the review of this state plan, CMS identified language pertaining to annuities that did not comply with federal requirements. During a conversation between CMS and the state of North Dakota on August 31, 2018, it was agreed that CMS would issue a companion letter along with the approval of the SPA. That letter is included as part of this approval package. Please note that this State Plan Amendment, ND-18-0015, was approved on September 28, 2018 and has an effective date of July 1, 2018. Enclosed with this approval package are the CMS-179, the approved pages, and the companion letter. Should you have any questions concerning this amendment, please contact Kirstin Michel at (303) 844-7036. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid and Children’s Health Operations

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Denver Regional Office 1961 Stout Street, Room 08-148 Denver, CO 80294 REGION VIII - DENVER October 1, 2018 Maggie Anderson, Medicaid Director North Dakota Department of Human Services Medical Services Division 600 E. Boulevard Avenue, Dept. 325 Bismarck, ND 58505 Dear Ms. Anderson: This letter is being sent as a companion to the Centers for Medicare and Medicaid Services’ ( CMS) approval of North Dakota’s State Plan Amendment (SPA) 18-0015, which proposed to add the eligibility group described at section 1902(a)(10)(A)(ii)(VI) of the Social Security Act (“Act”) and implemented at 42 CFR §435.217 of the regulations to North Dakota Medicaid’s State Plan. This SPA also proposed, under the authority of section 1902(r)(2) of the Act, to disregard parental resources from consideration in determining eligibility for children under that eligibility group. As part of its review of North Dakota’s SPA, CMS found state plan pages containing material that is inconsistent with federal law. On supplement 8b to attachment 2.6-A, pages 5-7, North Dakota lists several requirements for the treatment of annuities which must be met in order to exempt annuities from being considered as an available resource in a Medicaid eligibility determination. Separate from the evaluation of whether a purchased annuity is an asset transfer for less than fair market value is the determination of whether the annuity is a source of income or a countable resource. For individuals who seek eligibility on the basis of being 65 years old or older, or having blindness or disability, this would be determined, as required by sections 1902(a)(17) and 1902(r)(2) of the Act, based on the financial eligibility methodologies of the supplemental security income (SSI) program, unless North Dakota has received approval to apply a more restrictive methodology relating to annuities that was in North Dakota’s 1972 state plan under section 1902(f) of the Act. Generally, while the income stream provided by a financial instrument such as an annuity is appropriately considered income, under SSI methodologies, a financial instrument is only a resource when an individual has an ownership interest in the instrument and has the authority to convert its corpus to cash and use the cash for his or her maintenance needs. Ordinarily, an individual who purchases an annuity has surrendered the funds used for the purchase in exchange for periodic payments. It appears, however, that the annuity policy described on supplement 8b to attachment 2.6-A, pages 5-7, of North Dakota’s state plan deems the funds used to purchase an annuity as available to an individual who purchases the annuity, without regard to whether the corpus of the annuity is actually available to the individual under SSI rules. It further does not appear that the annuity policy described on these pages is a policy that was part of North Dakota’s 1972 state plan.

CMS discussed its concerns with the state regarding its treatment of annuities on August 31, 2018. This letter follows that conversation. North Dakota could either revise pages 5-7 of Supplement 8b to Attachment 2.6-A to remove paragraph 9 (“The value of an annuity that meets the following criteria is excluded”) or revise paragraph 9 to only count the corpus of annuities as an available resource when the corpus is available to the annuitant. Please respond within 90 days of receipt of this letter with either an explanation of why North Dakota’s treatment of annuities is consistent with sections 1902(a)(17) and 1902(r)(2) of the Act or submit a SPA to bring the state plan into compliance. During this 90-day period, CMS welcomes the opportunity to work with you and your staff. Should you or your staff have any questions, please contact Stephanie Kaminsky, Director, Division of Medicaid Eligibility and Policy at Stephanie.Kaminsky@cms.hhs.gov. Sincerely, Richard C. Allen Associate Regional Administrator Division of Medicaid & Children’s Health Operations

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): I. TRANSMITTAL NUMBER: 18-0015 3. PROGRAM IDENTIFICATION: FORM APPROVED 0MB NO 0938-0193 2. STATE North Dakota TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAID) 4. PROPOSED EFFECTIVE DATE July 1, 2018 0 NEW STATE PLAN 0 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: 7. FEDERAL BUDGET IMPACT: 42 CFR 435.217; Sec. 1902(r)(2) SSA (allowing for disregards) a. FFY 2018 $ NONE b. FFY 2019 $ NONE 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTIONOR ATTACHMENT (IfApplicable): Attachment 2.2-A Page 11 Attachment 2.2-A Page 11 Supplement 8b to Attachment 2.6-A Page 9 I0. SUBJECT OF AMENDMENT: This amendment adds eligibility to the state plan pursuant to 42 CFR §435.217 and allows for the exclusion of resources of parents of children who receive home and community based resources under this eligibility group. 11. GOVERNOR' S REVIEW (Check One): 0 GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: 0 COMMENTS OF GOVERNOR' S OFFICE ENCLOSED Maggie D. Anderson, Director 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Medical Services Division 12. SIGNATIJ i:: ru;.. ST GENCY OFFlCIA)o:, t.. 16. RETURN TO: Mae: e: ieD. Anderson Medical Services Division 14. TITLE: ND Department of Human Services Director, Medical Services Division 600 East Boulevard Avenue Dept 325 15. DATE SUBMITTED: Bismarck ND 58505- 025015-( 4-/ 8 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. Regional Administrator

Revision: HCFA-PM-91-10 December 1991 ( MB ) Attachment 2.2-A Page 11 State/Territory: North Dakota Agency* Citation(s) Groups Covered 42 CFR 435.217 B. Optional Groups Other Than the MedicallyNeedy ( Continued) X__ 4. A group or groups of individuals who would be eligible for Medicaid under the plan if they were in a NF or an ICF/MR, who but for the provision of home and community-based services under a waiver granted under 42 CFR Part 441, Subpart G would require institutionalization, and who will receive home and community-based services under the waiver. The group or groups covered are listed in the waiver request. This option is effective on the effective date of the State's section 1915(c) waiver under which this group(s) is covered. In the event an existing 1915(c) waiver is amended to cover this group(s), this option is effective on the effective date of the amendment. Agency that determines eligibility for coverage. ND Dept. of Human Services. TN No. 18-0015 Supersedes Approval Date ___9/28/18_____ Effective Date 0701/2018 TN No. 94-004

TN No.: 18-0015 Supersedes Approval Date: _9/28/18________ Effective Date: 07/01/2018 TN No.: NEW Revision: MARCH 2010 Supplement 8b to ATTACHMENT 2.6-A Page 9 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: NORTH DAKOTA MORE LIBERAL METHODS OF TREATING RESOURCES UNDER SECTION 1902(r)(2) OF THE ACT* X Section 1902(f) State _____ Non-Section 1902(f) State 11. The State disregards parental assets (resources) for children who are eligible for Medicaid under 42 CFR 435.217.

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Table of Contents State/Territory Name: New Hampshire State Plan Amendment (SPA) #: 19-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services JFK Federal Building, Government Center Room 2275 Boston, Massachusetts 02203 Boston Regional Operations Group October 8, 2019 Jeffrey A. Meyers, Commissioner Department of Health and Human Services State of New Hampshire 129 Pleasant Street Concord, NH 03301 Dear Commissioner Meyers, Enclosed is an approved copy of New Hampshire’s (NH) State Plan Amendment (SPA) No 19- 0003 entitled, “Durable medical equipment and supplies pricing in accordance with federal 21st Century Cures Act,” which transmitted language to amend the NH Title XIX State plan in order to comply with requirements of the Cures Act. This state plan amendment was submitted in the quarter ending March 31, 2019, for an effective date of January 1, 2019. Please note that our approval relates only to the requested change in payment methodology and CMS may still have questions on the funding structure in determining its consistent with section 1902(a)(2) and 1903(a) of the Act as implemented by 42 CFR § 433.54. Therefore, our approval relates only to the requested change in payment methodology and that the resultant rates and related expenditures are consistent with section 1902(a)(30)(A) of the Act. Approval of the subject SPA does not relieve the State of its responsibility to comply with federal laws and regulations, and to ensure that claims for federal funding are consistent with all applicable requirements. If there are questions, please contact Joyce Butterworth at (603) 545-2941 or by e-mail at Joyce.Butterworth@cms.hhs.gov. Sincerely, Francis T. McCullough Director Division of Medicaid Field Operations East (Boston) Enclosure/s cc: Henry Lipman, State Medicaid Director Diane Peterson, Medicaid Business and Policy /s/

DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STA TE PLAN MATERIAL 1. TRANSMITTAL NUMBER 19-0003 -- --- 2.STATE NH FORM APPROVED 0MB No ot38,0193 FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One) 4. PROPOSED EFFECTIVE DATE January 1, 2019 1 0NEW STATE PLAN 0AMENDMENT TO BE CONSIDERED AS NEW PLAN (81AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transnittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT 42 CFR Part 447 a Remainder of FFV 2019: ($3,141) b. FFY 2020: $4 187 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 4.19-8, page 2 (No changes to service pages) 10. SUBJECT OF AMENDMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT ("AppBcable) Attachment 4. 19-8, page 2, TN 18-0006 Durable medical equipment and supplies pricing in accordance with federal 21st Century Cures Act 11. GOVERNOR'S REVIEW (Check One} ' 0GOVERNOR'S OFFICE REPORTED NO COMMENT 18JOTHER, AS SPECIFIED: comments, If any, wlH follow 0COMMENTS OF GOVERNOR'S OFFICE ENCLOSED - ONO R PLY RECEIVED WITHIN 4'5 DAYS OF SUBMITTAL 15. DATE SUBMITTED FORREG OFFICE USE O l. Y 17. DATE RECEIVED 118. DATE APPROVED PLAN APPROVED - ONE COPY An'ACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONAL OFFICIAL 21. TYPED NAME 22. TITLE 23.REMARKS FORM CMS-1711 (07192) 03/11/2019 01/01/2019 Director Division of Medicaid Field Operations East (Boston) Francis T. McCullough 10/08/2019 /s/ /s/

Title XIX – NH

Attachment 4.19-B

Page 2

PAYMENT RATES FOR ALL TYPES OF CARE OTHER THAN INPATIENT HOSPITAL, SKILLED NURSING, OR INTERMEDIATE NURSING CARE SERVICES

7. Home Health Care Services – Payment rates for nursing and home health aide services are established in accordance with state statute A unit means a 15 minute unit. Skilled nursing services are reimbursed a flat rate per visit. Home health aide visits composed of fewer than 8 units of direct care time are reimbursed a flat rate per visit. Home health aide visits composed of eight or more units of direct care time are reimbursed a flat rate per unit of direct care time. The agency’s rates were set on April 1, 2010 and are effective for services provided on or after that date. Physical, occupational, and speech therapy/audiology services are reimbursed a per unit rate set by the department and in accordance with # 11 below. Medical supplies, equipment and appliances are reimbursed at rates set by the department. No provider shall bill or charge the department more than the provider's usual and customary charge. The fee schedule, which is applicable to all public and private providers of home health care services, can be accessed at www.nhmmis.nh.gov, under the “documents and forms” tab under “documentation.” For equipment which is prior authorized, the approved reimbursement amount, which is based upon the provider's acquisition and retail costs and other individualized circumstances of the request such as rental/trial periods, accessories, etc., is provided on the prior authorization approval notice which is sent to the provider. For those supplies, equipment and appliances which are not individually priced based on the above circumstances, rates were set on January 1, 2019, and are effective for services provided on or after that date.

8. Private Duty Nursing Services – Payment is made at a fee per hour in accordance with a fee schedule established by the department, with such fee schedule assigning fees based on day/evening hours, or night and weekend hours, or a more intensive level of care. Rates were set as of April 1, 2016, and are effective for services provided on or after that date. No provider shall bill or charge the department more than the provider's usual and customary charge. All fee schedules are accessible at www.nhmmis.nh.gov, under the “documents and forms” tab under “documentation,” and are applicable to all public and private providers.

9. Clinic Services – The individual practitioners who practice in the clinics are reimbursed according to the methodologies described in various entries in the state plan for the various types of practitioners providing the service. All fee schedules are accessible at www.nhmmis.nh.gov, under the “documents and forms” tab under “documentation,” and are applicable to all public and private providers.

TN No: 19-0003 Supersedes

Approval Date 10/08/2019 Effective Date: 01/01/2019 TN No: 16-0006

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: 19-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, MD 21244-1850 Financial Management Group Caprice Knapp Director ND Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250 Re: North Dakota 19-0006 Dear Ms. Knapp: We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid State plan submitted under transmittal number (TN) 19-0006. Effective for services on or after July 1, 2019, this amendment updates the state plan by extending the supplemental payment for critical access hospitals (CAHs) for an additional two-year period. We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a) and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We are pleased to inform you that Medicaid State plan amendment TN 19-0006 is approved effective July 1, 2019. The CMS-179 and the amended plan page are attached. If you have any questions, please contact Christine Storey at (303) 844-7044. Sincerely, Karen Shields Acting Director June 30, 2020

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES

FORM APPROVED OMB NO. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES

1. TRANSMITTAL NUMBER:

19-0006

2. STATE North Dakota

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

(MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES July 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 ANAMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

42 CFR 447 subpart C

7. FEDERAL BUDGET IMPACT:

a. FFY _ 2019 $462,000 b. FFY _ 2020 $607,000

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-A, page 9

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

Attachment 4.19-A, page 9

10. SUBJECT OF AMENDMENT:

Amends the State Plan to update the supplement payment for Critical Access Hospitals effective July 1, 2019.

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:

Caprice Knapp. Director Medical Services Division

12. SIGNATURE OF STATE AGENCY OFFICIAL:

13. TYPED NAME: Caprice Knapp

14. TITLE: Director, Medical Services Division

15. DATE SUBMITTED: Original Date: September 23, 2019 Resubmission Date: April 15, 2020

16. RETURN TO:

Caprice Knapp, Director

Medical Services Division

ND Department of Human Services 600 East Boulevard Avenue Dept 325 Bismarck ND 58505-0250

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

18. DATE APPROVED: 6/30/20

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL: TANS

21. TYPED NAME: Karen Shields

22. TITLE: Acting Director, FMG

23. REMARKS:

FORM CMS-179 (07-92)

STATE: North Dakota Attachment 4.19-A Page 9 ________________________________________________________________________________ TN No. 19-0006 Supersedes Approval Date_____________ Effective Date_07-01-2019___ TN No. 17-0018 Supplemental Payment for Inpatient Hospital Services provided by Critical Access Hospitals. Effective July 1, 2019, a North Dakota in-state critical access hospital shall receive up to three supplemental payments payable with the first payment being made no sooner than the quarter ending September 30, 2019 but not later than the quarter ending June 30, 2020, the second payment being made no sooner than the quarter ending September 30, 2020 but no later than the quarter ending December 31, 2020 and the third payment being made no sooner than the quarter ending March 31, 2021 but no later than the quarter ending June 30, 2021. The supplemental payment shall be made in combination with the cost settlement to reasonable costs. The purpose of the supplemental payments is to provide additional payment to qualifying hospitals for inpatient services provided to Medicaid eligible individuals. The calculation of the annual supplemental payment shall be made based on the hospital's costs for inpatient and outpatient laboratory and certified registered nurse anesthetists services provided to Medicaid eligible individuals as reported on the hospital's most recent Medicare cost report that has been audited and finalized by the Medicare fiscal intermediary less the payment, from all funding sources, received during the same cost report period for covered laboratory and certified registered nurse anesthetist services provided to Medicaid eligible individuals. The supplemental payment established in accordance with this provision may not exceed the difference between the inpatient Medicaid expenditures and the Medicare upper payment limit, in the aggregate, for inpatient hospital services, as defined in 42 CFR 447.272. If a payment is made during the first, second or third quarter of the state fiscal year (SFY), it will not exceed 25, 50 or 75 percent of the available UPL, respectively. If the payment amount is not paid in its entirety due to its exceeding the UPL availability for any given quarter, then the remainder not paid during that quarter will be paid in the following quarter, up to the available UPL room left for the SFY. The supplemental payment applies to private and nonstate governmental critical access hospitals. Qualifying providers are exempt from the cost limitations on page 2 of this section. 6/30/20

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: 19- 0010 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages TN: ND- 19- 0010 Approval Date: 09/ 04/ 2019 Effective Date: 07/ 01/ 2019

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1961 Stout Street, Room 08- 148 Denver, CO 80294 rc ARE& MEDICAID SERVICES Denver Regional Operations Group CENTER FOR MEDICAID& CHIP SERVICES September 5, 2019 Caprice Knapp, Medicaid Director Division of Medical Services North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505- 0250 Dear Ms. Knapp: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number (TN) 19- 0010. This amendment provides for a two percent increase to the vaccine administration fee reimbursed under the Vaccines for Children program. Please be informed that this State Plan Amendment was approved September 4, 2019 with an effective date of July 1, 2019. We are enclosing the CMS- 179 and the amended plan page( s). If you have any questions concerning this amendment, please contact Kirstin Michel at 303) 844- 7036. Sincerely, Richard C. Allen Director, Western Regional Operations Group Denver Regional Office Centers for Medicaid and CHIP Services cc: Krista Fremming, North Dakota Stacey Koehly, North Dakota

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO. 0938- 0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 19- 0010 North Dakota FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 3• PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT MEDIC ID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES July 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 or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: a. FFY 2019 4,857 42 CFR 447.405, 447. 10 and 447.415 b. FFY 2020 19,426 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( IfApplicable): Page 66( b) of Section 4 of the State Plan Page 66( b) of Section 4 of the State Plan 10. SUBJECT OF AMENDMENT: Amends the State Plan to implement an increase to the professional fee schedule for vaccines under the Pediatric Immunization program. 11. GOVERNOR' S REVIEW( Check One): GOVERNOR' S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR' S OFFICE ENCLOSED Erik Elkins, Assistant Director NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Medical Services Division 12. SIGNA ENCY OFFICIAL: 16. RETURN TO: 13. TYPED NAME: Erik Elkins, Assistant Director Erik Elkins Medical Services Division 14. TITLE: ND Department of Human Services Assistant Director, Medical Services Division 600 East Boulevard Avenue Dept 325 15. DATE SUBM ED: Bismarck ND 58505-0250 Z3 / FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18, DATE APPROVED: August 23, 2019 1 September 4, 2019 PLAN APPROVED-- ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: July 1, 2019 21. TYPED NAME: 22. TITLE: Richard C. Allen Director WROG 23. REMARKS: FORM CMS- 179( 07- 92)

66( b) Revision: HCFA- PM- 94-9 ( MB) JUNE 2009 State/Territory: North Dakota Citation 4. 19 ( m) Medicaid Reimbursement for Administration of Vaccines Under the Pediatric Immunization Program 1928 ( c) (2) i) A provider may impose a charge for the C) ( ii) of the Act administration of a qualified pediatric vaccine as stated I 1928(c) ( ii) of the Act. Within this overall provision, Medicaid reimbursement to providers will be administered as follows: ii) The State: sets a payment rate at the level of the regional maximum established by the DHHS Secretary. is a Universal Purchase State and sets a payment rate at the level of the regional maximum established in accordance with State law. sets a payment rate below the level of the regional maximum established by the DHHS Secretary. The reimbursement rates are the same for both public and private providers. Administration fees will be updated by annual or periodic adjustments to the professional services fee schedule. The reimbursement rate for initial immunization administrations is $ 15. 80; for subsequent immunization vaccine administration $ 15. 80; and for subsequent intranasal/oral vaccine administration 15. 80. is a Universal Purchase State and sets a payment rate below the level of the regional maximum established by the Universal purchase State. TN No: 19- 0010 Supersedes Approval Date: 09/04/2019 Effective Date: July 1, 2019 TN No: 15-003

_____________________________________________________________________________

Table of Contents

State/Territory Name: North Dakota State Plan Amendment (SPA) #: 19-0014 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages

TN: ND-19-0014 Approval Date: 05/12/2020 Effective Date: 07/01/2010

Records / Submission Packages - View All ND - Submission Package - ND2019MS0001O - (ND-19-0014) - Eligibility CMS-10434 OMB 0938-1188 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Division of Progam Operations 601 E. 12th Street Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services May 13, 2020 Christopher Jones Executive Director ND Medical Services Dept 325 600 E Boulevard Ave Bismarck, ND 58505 Re: Approval of State Plan Amendment ND-19-0014 Dear Christopher Jones: On September 27, 2019, the Centers for Medicare and Medicaid Services (CMS) received North Dakota State Plan Amendment (SPA) ND-19- 0014 to amend the State Plan to increase the eligibility income level for children with disabilities to 250% of the FPL effective July 1, 2019. The following Reviewable Units were included in this submission package as this is the first SPA North Dakota has completed in MACPro: Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability, Non-MAGI Methodologies, More Restrictive Requirements than SSI under 1902(f) - (209(b) States), Handling of Excess Income (Spenddown), Mandatory Eligibility Groups, Individuals in 209(b) States Who Are Age 65 or Older or Who have Blindness or a Disability, and Optional Eligibility Groups.. We approve North Dakota State Plan Amendment (SPA) ND-19-0014 on May 13, 2020 with an effective date(s) of July 01, 2019. CMS acknowledges that North Dakota is working to bring its annuities methodology into compliance with federal law, with the submission of SPA ND 19-0017. This SPA was submitted in response to the companion letter that CMS issued with the approval of SPA ND 18-0015 on October 1, 2018. Name Date Created No items available If you have any questions regarding this amendment, please contact Curtis Volesky at curtis.volesky@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter RAI Transaction Logs News Related Actions Page 1 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID N/A SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date N/A State Information State/Territory Name: North Dakota Medicaid Agency Name: ND Medical Services Submission Component State Plan Amendment Medicaid CHIP Page 2 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID N/A SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date N/A SPA ID and Effective Date SPA ID ND-19-0014 Reviewable Unit Proposed Effective Date Superseded SPA ID Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability 7/1/2019 ND-92-010 Non-MAGI Methodologies 7/1/2019 ND-92-010 More Restrictive Requirements than SSI under 1902(f) - (209(b) States) 7/1/2019 ND-93-13 Handling of Excess Income (Spenddown) 7/1/2019 ND-93-13 Mandatory Eligibility Groups 7/1/2019 ND-13-0017 Individuals in 209(b) States Who Are Age 65 or Older or Who have Blindness or a Disability 7/1/2019 ND-92-010 Optional Eligibility Groups 7/1/2019 ND-13-0017 Family Opportunity Act Children with a Disability 7/1/2019 ND-08-002 Page Number of the Superseded Plan Section or Attachment (If Applicable): Page 3 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID N/A SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives Amends the State Plan to increase the eligibility income level for children with disabilities to 250% of the FPL effective July 1, 2019. The following Reviewable Units were included in this submission package as this is the first SPA North Dakota has completed in MACPro: Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability, Non-MAGI Methodologies, More Restrictive Requirements than SSI under 1902(f) - (209(b) States), Handling of Excess Income (Spenddown), Mandatory Eligibility Groups, Individuals in 209(b) States Who Are Age 65 or Older or Who have Blindness or a Disability, and Optional Eligibility Groups. There were no changes to the information in these Reviewable Units. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 $155178 Second 2020 $620712 Federal Statute / Regulation Citation 1902(a)(10)(A)(ii)(XIX) of the Act Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available Page 4 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID N/A SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other Describe Authority to prepare and submit Medicaid State Plans is provided to the Medicaid single state agency Page 5 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID N/A SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date N/A Indicate whether public comment was solicited with respect to this submission. Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Page 6 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID N/A SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state Yes No This state plan amendment is likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Yes No  The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner:  All Indian Health Programs Date of solicitation/consultation: Method of solicitation/consultation: 7/1/2019 letter 8/20/2019 tribal consultation meeting All Urban Indian Organizations States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below:  All Indian Tribes Date of consultation: Method of consultation: 7/1/2019 letter 8/20/2019 tribal consultation meeting The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created Kirstin Michel 9/26/2019 8:56 PM EDT Page 7 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Name Date Created Attendee List 10/25/2019 11:56 AM EDT Indicate the key issues raised (optional) Access Quality Cost Payment methodology Eligibility Benefits Service delivery Other issue Page 8 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medicaid State Plan Eligibility Income/Resource Methodologies Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a Disability Eligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following: 1. SSA Eligibility Determination State (1634 State) The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneficiaries. For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, the state requires a separate Medicaid application and determines financial eligibility based on SSI income and resource methodologies. 2. State Eligibility Determination (SSI Criteria State) The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility based on SSI income and resource methodologies. 3. State Eligibility Determination (209(b) State) The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility using income and resource methodologies more restrictive than SSI. B. Additional information (optional) Page 9 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medicaid State Plan Eligibility Income/Resource Methodologies Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 The state will apply the methodologies as described below, and consistent with 42 CFR 435.601, 435.602, and 435.831. A. Basic Financial Methodology 1. The state applies the income and resource methodologies of the SSI program when determining eligibility for a population based on age (65 or older) or having blindness or a disability, with the exceptions described below in B. through G. 2. The state applies the financial methodologies of either the SSI program or the AFDC program in effect as of July 16, 1996 (whichever is most closely related) when determining eligibility for a population based on age (as a child), pregnancy, or status as a caretaker relative, with the exceptions described below in B. through G. B. Use of Less Restrictive and More Restrictive Methodologies 1. The state elects to apply income and/or resources methodologies that are less restrictive than those used under the cash assistance programs, in accordance with 42 CFR 435.601(d). Yes No 2. The less restrictive income and resource methodologies are described on the RU for each applicable eligibility group. 3. The state applies more restrictive financial eligibility requirements to individuals who are age 65 or older or who have blindness or disability. The more restrictive requirements are no more restrictive than those requirements contained in the state's Medicaid plan in effect on January 1, 1972. 4. The more restrictive requirements are described in More Restrictive Methodologies Under 1902(f). Page 10 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 C. Financial Responsibility of Relatives 1. In determining financial eligibility for an individual, the state does not include income and resources from anyone other than the individual's spouse, and for individuals under age 21 or who have blindness or disability, the individual's parent. a.The state includes the income and resources of a spouse or parent only when they are living with the individual in the same household, except as follows: i. In the case of spouses who are age 65 or older or who have blindness or disability and who share the same room in a Medicaid institution, the state: (1) Considers these couples either as living together or as living separately for the purpose of counting income and resources, whichever is more advantageous to the couple. (2) Considers these couples as living separately for the purpose of counting income and resources. ii. Where applicable, the state determines income and resource eligibility consistent with the spousal impoverishment rules of section 1924 of the Act, as described in the Resource Assessment and Eligibility reviewable unit. b. In the case of individuals under age 21 for whom AFDC is the most closely related cash assistance program, the income and resources of parents and spouses are included only if the individual would have been considered a dependent under the state's approved AFDC state plan in effect as of July 16, 1996. 2. In determining financial eligibility for individuals who are age 65 or older or who have blindness or a disability, the state may apply more restrictive requirements for relative responsibility than specified in B.1., but no more restrictive than the requirements under the Medicaid plan in effect on January 1, 1972. These methodologies are described in More Restrictive Methodologies under 1902(f). Page 11 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 D. Family Size 1. The family size of an individual for whom the SSI income and resource methodologies are used (as described in section A) includes the persons 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. Yes No a. Qualified Medicare Beneficiaries (described in section 1902(a)(10)(E)(i) of the Act) 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)(10)(E)(iv) of the Act) d. Qualified Disabled and Working Individuals (described in section 1902(a)(10)(E)(ii) of the Act) e. Age and Disability-Related Poverty Level (described in section 1902(a)(10)(A)(ii)(X) of the Act) f. Work Incentives (described in section 1902(a)(10)(A)(ii)(XIII) of the Act)  g. Family Opportunity Act Children with a Disability (described in section 1902(a)(10)(A)(ii)(XIX) 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. Yes No 5. For the selected FPL eligibility groups, family size is defined as follows: 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. b. The state uses another definition of family. Name of other definition: Description: Medicaid Unit An applicant or recipient who is the caretaker of a blind or disabled child under eighteen years of age may select any of their non-blind or disabled children to be included in the Medicaid unit. Anyone whose needs are included in the unit for any month is subject to all Medicaid requirements which may affect the unit. Page 12 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 E. Use of MAGI-like Methodologies 1. The state uses MAGI-like methodologies for one or more populations for whom the most closely related cash assistance program would be the AFDC program in effect as of July 16, 1996. Yes No 2. The election to use MAGI-like methodologies is described on the RU for each applicable eligibility group. 3. The MAGI-like methodology is consistent with 42 CFR 435.603(b) through (f) with respect to definitions, household income, and definition of household, except: a. The agency elects to use the MAGI definition of parent when considering the financial responsibility of relatives, which includes natural or biological parents, as well as adopted parents and stepparents. Yes No b. Less restrictive methodologies can be used, as described in section B. c. The financial responsibility requirements for relatives are applicable, as described in section C. d. The countable income deductions for the medically needy are applicable, when the MAGI-like methodologies are applied to the medically needy, as described in section F. Page 13 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 F. Countable Income Deductions for the Medically Needy In determining countable income for individuals who are age 65 or older or who have blindness or a disability, the state deducts: 1. Amounts that are no more restrictive than those used under the Medicaid plan on January 1, 1972, and no more liberal than those used in determining eligibility under SSI or an optional state supplement, and 2. Amounts that are at least the same as those that would be deducted in determining eligibility under the eligibility group for individuals in 209 (b) states who are age 65 or older or who have blindness or a disability (described in 42 CFR 435.121). Page 14 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Non-MAGI Methodologies MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 G. Additional Information (optional) Page 15 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medicaid State Plan Eligibility Income/Resource Methodologies More Restrictive Requirements than SSI under 1902(f) - (209(b) States) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-93-13 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 The state applies more restrictive requirements than SSI under the authority of section 1902(f) of the Act, and consistent with 42 CFR 435.121. A. Use of More Restrictive Requirements The state applies more restrictive eligibility requirements to individuals who are age 65 or older or who have blindness or disability. The more restrictive requirements are no more restrictive than those requirements contained in the state's Medicaid plan in effect on January 1, 1972. The state does not apply more restrictive requirements if: 1. The requirement conflicts with the requirements of section 1924 of the Act, which governs the eligibility and post-eligibility treatment of income and resources of institutionalized individuals with community spouses; 2. The requirement conflicts with a more liberal requirement which the agency has elected to use under 42 CFR 435.601; or 3. The more restrictive requirement conflicts with a more liberal requirement the state has elected to use under §435.234(c) in determining eligibility for State supplementary payments. B. Populations with More Restrictive Requirements The state applies more restrictive requirements for the following populations:  1. Individuals age 65 or older  2. Individuals who have blindness  3. Individuals who have a disability C. Types of More Restrictive Requirements Used The state applies more restrictive requirements for the following populations:  1. The state uses more restrictive requirements with respect to income.  2. The state uses more restrictive requirements with respect to resources. 3. The state uses more restrictive requirements with respect to the definition of disability. 4. The state uses more restrictive requirements with respect to the definition of blindness. 5. The state uses more restrictive requirements with respect to financial responsibility of relatives. 6. The state uses other more restrictive requirements. Page 16 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

More Restrictive Requirements than SSI under 1902(f) - (209(b) States) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-93-13 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 D. More Restrictive Requirements with Respect to Income The following more restrictive requirements are used with respect to income: 1. The state uses a lower income standard than the SSI or the Optional State Supplement standard for eligibility groups under Mandatory Coverage and Options for Coverage. 2. The state uses more restrictive income disregards or exclusions.  3. The state uses more restrictive requirements with respect to income from self employment. Description: No income from any other source may be used to offset a self- employment loss.  4. The state uses more restrictive requirements with respect to irregular/infrequent income. Description: All infrequent or irregular income is considered in the month received.  5. The state uses other more restrictive requirements with respect to income: Name of requirement: Description: Ineligible Medical Assistance Unit Twenty-five percent of that excess income of the ineligible medical assistance unit in the home which exceeds the appropriate medically needy income level will be deemed to be available to an eligible individual residing in a specialized facility Unearned Income Income from rental of rooms, apartments, or other property is unearned income, except that income from room rentals is considered "earned," if the recipient is actively engaged in the venture by such means as making the bed, changing linens, cleaning the room, etc. Veterans Benefits All veterans benefits (except Aid and Attendance) are considered non-exempt income for the Aged, Blind and Disabled. Lump Sum Income Non-recurring lump sum income is considered income in the month received and a resource thereafter except retroactive lump sum SSI payments which are disregarded in the month received. Page 17 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

More Restrictive Requirements than SSI under 1902(f) - (209(b) States) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-93-13 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 E. More Restrictive Requirements with Respect to Resources The following more restrictive requirements are used with respect to resources: 1. The state uses a lower resource standard than the SSI or the Optional State Supplement standard for eligibility groups under Mandatory Coverage and Options for Coverage.  2. The state uses more restrictive requirements with respect to the treatment of real property. a. The state uses a more restrictive requirement with respect to the treatment of home property.  b. The state uses other more restrictive requirements related to real property. Name of requirement: Description: Joint Ownership Real Property includes land, buildings, mineral rights, burial plots, contractual rights on real property, etc. Joint ownership of real property will be considered available on an equal basis unless otherwise specified.  3. The state uses more restrictive requirements with respect to the treatment of lump sums. Description: Retroactive lump-sum SSI income payments are counted as resources in the month following the month in which they are received.  4. The state uses more restrictive requirements with respect to the treatment of personal property. Description: Personal property includes cash surrender value of life insurance policies, vehicles, machinery, livestock, grave markers, burial vaults, contractual rights on personal property, etc. Joint ownership of personal property will be considered available on an equal basis unless otherwise specified.  5. The state uses other more restrictive requirements with respect to resources: Name of requirement: Description: Contract for Deed The essential feature of a " Contract for Deed" is the right to receive periodic payments, usually coupled with a right to get the property back if the payments are not made. Contractual rights to receive monthly payments also arise out of other types of Page 18 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Name of requirement: Description: transactions. The valuable contract documents may be called a note, accounts receivable, mortgage, or by some other name. Because many such contracts were entered into when interest rates were lower, the contracts are not negotiable at their face value. That is not to say they have no value. A proper valuation may be made by a process called " discounting", which will take into account the changes in the interest rates. The discounted value will be determined by the Legal Services Division of the Department of Human Services. A letter requesting the discounted value accompanied by the contract documents must be sent to the Legal Services Division. If the discounted value, alone or added to the value of other property, is in excess of program limits, the applicant/recipient is ineligible and may attempt to reduce property holdings to the allowable resource limits to establish eligibility. It is presumed that the contract, like any other property, is saleable without working an undue hardship. Personal Vehicle When one automobile or other personal vehicle is not exempt, because its primary purpose is not to serve the needs of members of the Medicaid unit, the entire value of the vehicle is counted as an asset. Resource Exemptions The home occupied by the individual or member of the Medical Assistance Unit will be exempt in determining eligibility for Medical Assistance. The home is defined as including the land on which it is located, providing the acreage does not exceed 160 contiguous acres if rural, or two acres if located in town. Acreage in excess of the 160 rural) or 2 ( if located in town) would be declared " Real Property Other Than the Home." The home will be considered "occupied" and exempt if the individual or Medical Assistance Unit is temporarily absent but actually intends, Page 19 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Name of requirement: Description: and is able, to return within a reasonable length of time; otherwise such property will be considered " Other Real Property." If the home is exempt for the aforementioned reason, adequate documentation and frequent review are required. The home of an individual in long term care or the State Hospital with no spouse or family at home may be considered exempt for a period of not more than six months when a physician has certified that the individual is likely to return to his home within that period. Parent Resources Except for individuals covered by Section 1924 of the Act, the resources of the parent( s) will be deemed available for those individuals who are in long term care, the State Hospital, or in a specialized facility and thus considered separated for purposes of the SSI Program. The resources of the spouse will be deemed available for these individuals who are in a specialized facility and thus considered separated for the purposes of the SSI Program. The medically needy resource provisions will be applied as though the individual( s) were all residing in the same household. Noninstitutionalized Spouse Except for individuals covered by Section 1924 of the Act, the ineligible, noninstitutionalized spouse who has lived apart from the applicant or recipient for at least six months may separately own resources ( liquid, personal or real) up to the maximum amount allowed. Income Producing Property All SSI recipients are subject to the medically needy resource limit regarding income producing property. Liquid Assets Liquid assets include actual cash, savings, redeemable stocks and bonds, accounts receivable, etc. Liquid assets can be replenished at any time and may be accumulated out of exempted income during periods of eligibility. Liquid assets held in joint ownership will be considered available in Page 20 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Name of requirement: Description: total to the Medical Assistance Unit. Burial Insurance Burial insurance is counted unless it specifically provides that the proceeds can be used only to pay burial expenses of the insured. Available Property Real or personal property which is essential to earning a livelihood is considered " available" in determining Medical Assistance eligibility unless the property owners are actively engaged in using the property to earn income and derive the total benefit of such income for their personal needs. An individual is actively engaged in utilizing the property if the individual contributes significant current personal labor in utilizing the property for income producing purposes. The payment of social security taxes on the income from such current personal labor is an indicator of the active utilization of the property. ( Property which merely produces rental or lease income will be considered available in determining Medical Assistance eligibility.) Funeral Set-Aside Funeral set -asides not usually counted in the funeral expense allowance of the SSI program, i. e., headstones, vaults, caskets, etc., are subject to a $4500 limitation over the Standard SSI 1500 limit, plus interest accrued. Page 21 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

More Restrictive Requirements than SSI under 1902(f) - (209(b) States) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-93-13 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 J. Income Deductions When applying more restrictive requirements, the state deducts SSI payments received by the individual and state supplement payments that meet the conditions specified in 42 CFR 435.232 and 435.234. The state also allows the following individuals to deduct incurred medical and remedial expenses (spend down) to become categorically eligible under the group for individuals in 209(b) states who are age 65 or over or who have blindness or a disability: 1. SSI beneficiaries and eligible spouses of SSI beneficiaries 2. State supplement recipients or individuals who are eligible for but not receiving a state supplementary payment. 3. Individuals who would be eligible for SSI/SSP but for OASDI COLA increases since April, 1977 (42 CFR 435.135) In determining countable income used for the purpose of calculating spend down for this population, the state deducts OADSI benefits, as follows: a. All of the OASDI benefits is deducted from income. b. Part of the OASDI benefits is deducted from income. c. None of the OASDI benefits is deducted from income. 4. Disabled widows and widowers ineligible for SSI due to increase in OASDI (42 CFR 435.137) In determining countable income used for the purpose of calculating spend down for this population, the state deducts OADSI benefits, as follows: a. All of the OASDI benefits is deducted from income. b. Part of the OASDI benefits is deducted from income. c. None of the OASDI benefits is deducted from income. 5. Disabled widows and widowers ineligible for SSI due to early receipt of social security (42 CFR 435.138) In determining countable income used for the purpose of calculating spend down for this population, the state deducts OADSI benefits, as follows: a. All of the OASDI benefits is deducted from income. b. Part of the OASDI benefits is deducted from income. c. None of the OASDI benefits is deducted from income. 6. Adult children with disabilities (1939(a)(2)(D) and 1634(c) of the Act) In determining countable income used for the purpose of calculating spend down for this population, the state deducts OASDI benefits, as follows: a. All of the OASDI benefits is deducted from income. b. Part of the OASDI benefits is deducted from income. c. None of the OASDI benefits is deducted from income. Page 22 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

More Restrictive Requirements than SSI under 1902(f) - (209(b) States) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-93-13 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 K. Additional Information (optional) Page 23 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

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Medicaid State Plan Eligibility Income/Resource Standards Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-93-13 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 If countable income exceeds the income standard, the state must deduct from income medical expenses incurred by the individual or family or financially responsible relatives that are not subject to payment by a third party, in accordance with 42 CFR 435.831 and 42 CFR 435.121. A. Budget Periods Income in excess of the appropriate income standard is considered available for payment of medical or remedial care expenses in budget periods that do not exceed six months. 1. In determining income eligibility, countable income is reduced by the amount of incurred medical or remedial care expenses during the budget period specified below: a. One budget period of: i. 6 months ii. 5 months iii. 4 months iv. 3 months v. 2 months vi. 1 month b. More than one budget period, as described below: Page 25 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-93-13 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 B. Types of Eligible Expenses 1. In determining incurred expenses to be deducted from income, the state includes: a. Medicare, Medicaid, and other health insurance premiums and enrollment fees. b. Cost sharing, including copayments, coinsurance, and deductibles, imposed by Medicare, Medicaid or other health insurance. c. Expenses for necessary medical and remedial services recognized by state law but not included in the state plan. d. Expenses for necessary medical and remedial services included in the state plan, including those that exceed limitations on the amount, duration, and scope of services. 2. The state also includes medical institutional expenses projected to the end of the budget period at the Medicaid reimbursement rate. Yes No 3. Incurred expenses subject to payment by a third party are not deducted unless the third party is a public program (other than Medicaid) of a state and the program is financed by the state. Page 26 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-93-13 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 C. Timeframe of Deduction of Expenses In determining incurred expenses to be deducted from income, the state deducts: 1. Incurred medical and remedial expenses without regard to the age of the expenses. 2. Payments made during the budget period on eligible expenses incurred at any time, if not previously deducted in establishing eligibility. 3. Unpaid eligible expenses incurred at any time prior to the budget period, which have not been deducted previously in establishing eligibility. Page 27 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-93-13 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 D. Order of Deduction of Expenses Incurred medical or remedial care expenses are deducted in the following order: 1. By the type of service, in the following order: a. Premiums, deductibles, coinsurance and co-payments. b. Expenses for necessary medical or remedial care services that are recognized under state law but not included in the State Plan. c. Expenses for necessary medical or remedial care services that are included in the state Plan that exceed agency limitations on amount, duration, or scope of services. d. Expenses for necessary medical or remedial care services that are included in the state Plan that are within the agency limitations on amount, duration, or scope of services. 2. In chronological order by the date of the service, or the date cost sharing payments are due. 3. In chronological order by the date the bill is submitted to the state by the individual. Page 28 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-93-13 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 E. Reasonable Limitations The state sets reasonable limits on the amount to be deducted for expenses. Yes No The state sets the following reasonable limits: 1. Medicare, Medicaid and other health insurance premiums and cost sharing.  2. Expenses for necessary medical and remedial services recognized by state law but not included in the state plan. Description of reasonable limitations: Incurred expenses that are subject to payment by a third party are not deducted unless the expenses are subject to payment by a third party that is a publicly funded program ( other than Medicaid) of a State or government. Page 29 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-93-13 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 F. Spenddown Payments Made by Individuals The state permits individuals to pay-in their spenddown liability. Yes No Page 30 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Handling of Excess Income (Spenddown) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-93-13 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 G. Additional Information (optional) Page 31 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Page 32 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-13-0017 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children NEW Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Individuals in 209(b) States Who Are Age 65 or Older or Who have Blindness or a Disability APPROVED Closed Eligibility Groups NEW NEW             Page 33 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Individuals Deemed To Be Receiving SSI Working Individuals under 1619(b) NEW Qualified Medicare Beneficiaries NEW Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries NEW Qualifying Individuals NEW      Page 34 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-13-0017 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 B. The state elects the Adult Group, described at 42 CFR 435.119. Yes No Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Adult Group CONVERTED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A  Page 35 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Individuals in 209(b) States Who Are Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 In 209(b) states, individuals who are 65 or older or who have blindness or a disability, who meet more restrictive criteria than used in SSI Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 The state covers the mandatory eligibility group for individuals in 209(b) states who are age 65 or older or who have blindness or a disability in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Be age 65 or older or have blindness or a disability; 2. Meet more restrictive requirements than SSI, as defined by the state in section B; 3. Have income and resources at or below the standard for this group. Page 36 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Individuals in 209(b) States Who Are Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 B. Financial Methodologies 1. The more restrictive requirements used are described in the More Restrictive Requirements than SSI under 1902(f) RU. 2. Less restrictive methodologies are used in calculating countable income. Yes No The less restrictive income methodologies are:  General income disregard: Name of disregard: Description: Guardian or Conservator The legally appointed guardian or conservator may be allowed to retain 5 percent of a recipient's monthly benefits as reimbursement for services. The remainder of the recipient's monthly benefit shall be considered available to the Medical Assistance Unit.  A specified amount of unearned income is disregarded. Amount: $25.00 Description of disregard: The first $25 of unearned income from rental of rooms, apartments, or other property from each unit is exempt to defray any associated expenses.  Census Bureau wages are disregarded. Description of disregard: All wages paid by the Census Bureau for temporary employment related to census activities are excluded.  Interest is disregarded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income.  Dividends are disregarded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income.  Training allowances and expenses are disregarded. Description of disregard: For each individual who is not an aged, blind, or disabled recipient within a family who is employed or in training, deduct the $30 standard work/ training expense allowance.  A specified type of income is disregarded: Page 37 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Name of income type: Description: Income In-Kind Income in- kind is to be excluded except that income in-kind which is in lieu of wages is considered earned income. Extra Checks of Earned or Unearned Income Extra checks of earned or unearned income received from a regularly recurring income source are disregarded as income. Bonus checks, or checks for any other reason, are not considered extra checks. The last check received in the month is considered the extra check. Child Care Costs Allow reasonable child care costs necessary for employment or training to be deducted from income. Payroll Deductions and Union Dues Gross earnings for employed individuals who are not aged, blind, or disabled applicants or recipients are reduced by mandatory payroll deductions and union dues actually withheld or actually paid or $90 whichever is greater. Child Support The First $50 per month of current child support, received on behalf of children in the Medicaid unit, will be disregarded from each budget unit that is budgeted with a separate income level. Adult Dependent Care Expenses Reasonable adult dependent care expenses incurred for any incapacitated or disabled adult in the Medicaid unit are allowed as a deduction from income so a caretaker or spouse can work or attend training. Car Safety Seat The cost to purchase or rent a car safety seat for a child through age 10 is allowed as a deduction if a seat is not otherwise reasonably available. Subsidized Guardianship Payments Disregard subsidized guardianship payments for children. Child and Adult Food Program Disregard payments from the Child and Adult Food Program for meals and snacks to licensed families who provide daycare in their home. Military Personnel Additional Pay Additional pay received by military personnel as a result of deployment to a combat zone is disregarded as income. Page 38 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Name of income type: Description: TANF Cash Grant Disregard TANF cash grant as income. 3. Less restrictive methodologies are used in calculating countable resources. Yes No The less restrictive resource methodologies are:  The state uses a less restrictive methodology with respect to resources set aside for burial.  Specified methodology for the treatment of resources set aside for burial: Name of methodology: Description: Burial Funds Any prepayments or deposits which total $6,000 or less which are designated and maintained by an applicant or recipient for their burial. The earnings accrued on the burial fund are excluded. A fund is considered to be designated for burial if identified as such on the account or by the applicant or recipient's statement.  A specified type of resource is disregarded: Name of resource type: Description: Resource Standards Disregard countable resources, for single individuals, between $2,000 and $3,000, and, for couples (or 2-person households), between $3,000 and $6,000 (+$25 for each additional individual). Salability of "Contractual Rights to Receive Payment" An applicant/recipient may rebut the presumption of the salability of "contractual rights to receive payment" by showing the following. a. That his interest in the contract was advertised for sale in a newspaper whose circulation area includes the area where the real property relating to the contract is located. This advertisement must be published successively for two weeks if the newspaper is a weekly and for one week if it is a daily. b.The sworn statement of the applicant/ recipient that no offers were received which equaled or exceeded the minimum price. If all offers were below the minimum price, the property is determined to be not saleable; Page 39 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Name of resource type: Description: any offer received that is equal to or in excess of the minimum price will establish that the property is saleable and the seller has the right to accept any of the offers. Rebuttals must be made immediately prior to each redetermination of eligibility for the property to continue to be treated as unsalable. Effective Date of Eligibility Effective Date of Eligibility - An individual is considered resource eligible for the full month if he/she attains resource eligibility on any day of the month, without regard to whether the individual was resource eligible on the first moment of the first day of the month. Life Estate Effective July 1, 1996 the value of a life estate will be excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Value of Mineral Acres The value of mineral acres are excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Employee Benefit Annuity The value of an employee benefit annuity that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simplified employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in § 408 of the Internal Revenue Code of 1986 is excluded. Annuities The value of an annuity that meets the following criteria is excluded: a. The annuity if irrevocable and cannot be assigned to another person; b. The issuing entity is an insurance company or other commercial company that sells annuities as part of the normal course of business; c. The annuity provides for level monthly payments; d. If the annuity was purchased before August 1, 2005, the annuity returns the full purchase price and Page 40 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Name of resource type: Description: interest within the purchaser's life expectancy; e. If the annuity was purchased on or after August 1, 2005, the annuity returns the full principle and has a guaranteed period that is equal to at least 85% of the annuitant's life expectancy; f. If the annuity was purchased before August 1, 2005, the monthly payments from the annuity do not exceed the minimum monthly maintenance needs allowance pursuant to § 1924(d)( 3) of the Act. g. If the annuity was purchased on or after August 1, 2005, the monthly payments from all annuities that meet these requirements do not exceed the minimum monthly maintenance needs allowance pursuant to § 1924(d)( 3) of the Act and, when combined with the annuitant's other income at the time of application for Medicaid, does not exceed 150% of the minimum monthly maintenance needs allowance; and h. If the annuity was purchased on or after August 1, 2005, if the applicant for Medicaid is age 55 or older, the North Dakota Department of Human Services is irrevocably named as the primary beneficiary of the annuity following the death of the applicant and the applicant's spouse, not to exceed the amount of benefits paid by Medicaid. If a minor child who resided and was supported financially by the applicant or spouse, or disabled child, survives the applicant and spouse, any payments from the annuity will be provided to those individuals. State Tax Refunds State tax refunds and refundable tax credits are excluded as resources for nine months beginning after the month of receipt. Real or Personal Property Real or personal property which is not saleable without working an undue hardship may be considered unavailable in determining Page 41 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Name of resource type: Description: Medical Assistance eligibility. Property which has been, in good faith, offered for sale, and for which no offer has been received which equals or exceeds 75% of the reasonable market value, will normally be treated as not saleable without working an undue hardship. A good faith offer to sell real property would normally include advertisements and listings with real estate agents or local dealers in real estate. The reasonable market value of real property may be established by appraisal or by any other method which is likely to produce an accurate valuation. Valuations established for real estate tax purposes shall not be used. A good faith offer to sell personal property would normally include advertisements, listing with real estate agents or local dealers. The reasonable market value of personal property may be established by appraisals or by any other method which is likely to produce an accurate valuation. Page 42 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Individuals in 209(b) States Who Are Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 C. Income Standard Used The income standard for this group is: 1. A percentage of the federal poverty level: 2. A dollar amount 3. Another standard Statewide standard The statewide standard is: Household size Standard 1 $500.00 2 $516.00 3 $666.00 4 $800.00 5 $908.00 6 $1008.00 7 $1083.00 8 $1141.00 9 $1200.00 10 $1250.00 The state uses an additional incremental amount for larger household sizes. Yes No Incremental Amount $57.00 The dollar amounts increase automatically each year Yes No Page 43 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Individuals in 209(b) States Who Are Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 D. Resource Standard Used The resource standard for this group is: Individual: $2000.00 Couple: $3000.00 Page 44 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Individuals in 209(b) States Who Are Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 E. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is defined in the Handling of Excess Income (Spenddown) RU. Page 45 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Individuals in 209(b) States Who Are Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-92-010 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 F. Additional Information (optional) Page 46 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-13-0017 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. Yes No The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper-based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classifications of Individuals under Age 21 NEW Children with Non- IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents NEW Optional Targeted Low Income Children NEW Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled   Page 47 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance NEW Individuals Eligible for Cash Except for Institutionalization NEW Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneficiaries NEW Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives NEW Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability APPROVED Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW      Page 48 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-13-0017 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 B. Medically Needy Options for Coverage The state provides Medicaid to specified groups of individuals who are medically needy. Yes No The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Pregnant Women NEW Medically Needy Children under Age 18 NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Protected Medically Needy Individuals Who Were Eligible in 1973 NEW 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Reasonable Classifications of Individuals under Age 21 NEW Medically Needy Parents and Other Caretaker Relatives NEW Aged, Blind and Disabled      Page 49 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Populations Based on Age, Blindness or Disability NEW  Page 50 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-13-0017 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A Page 51 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Eligibility Groups - Options for Coverage Family Opportunity Act Children with a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Children under age 19 who are considered to have a disability, with income equal to or less than a standard specified by the state. Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-08-002 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 The state operates the Family Opportunity Act Children with a Disability eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 19; 2. Would be considered disabled under section 1614(a)(3)(C) of the Act, without regard to any income or asset eligibility requirements that apply under such title; and 3. Have income that does not exceed the standard established by the state Page 52 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Family Opportunity Act Children with a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-08-002 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. More restrictive requirements than SSI are used in calculating countable income. Please refer as necessary to More Restrictive Requirements than SSI under 1902(f), completed by the state. 3. Less restrictive methodologies are used in calculating countable income. Yes No The less restrictive income methodologies are:  General income disregard: Name of disregard: Description: Guardian or Conservator The legally appointed guardian or conservator may be allowed to retain 5 percent of a recipient' s monthly benefits as reimbursement for services. The remainder of the recipient's monthly benefit shall be considered available to the Medical Assistance Unit.  A specified amount of unearned income is disregarded. Amount: $25.00 Description of disregard: The first $25 of unearned income from rental of rooms, apartments, or other property from each unit is exempt to defray any associated expenses.  Census Bureau wages are disregarded. Description of disregard: All wages paid by the Census Bureau for temporary employment related to census activities are excluded.  Interest is disregarded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income.  Dividends are disregarded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income.  Training allowances and expenses are disregarded. Description of disregard: For each individual who is not an aged, blind, or disabled recipient within a family who is employed or in training, deduct Page 53 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

the $30 standard work/ training expense allowance.  A specified type of income is disregarded: Name of income type: Description: Income In-Kind Income in-kind is to be excluded except that income in-kind which is in lieu of wages is considered earned income. Extra Checks of Earned or Unearned Income Extra checks of earned or unearned income received from a regularly recurring income source are disregarded as income. Bonus checks, or checks for any other reason, are not considered extra checks. The last check received in the month is considered the extra check. Child Care Costs Allow reasonable child care costs necessary for employment or training to be deducted from income. Payroll Deductions and Union Dues Gross earnings for employed individuals who are not aged, blind, or disabled applicants or recipients are reduced by mandatory payroll deductions and union dues actually withheld or actually paid or $90 whichever is greater. Child Support The First $50 per month of current child support, received on behalf of children in the Medicaid unit, will be disregarded from each budget unit that is budgeted with a separate income level. Adult Dependent Care Expenses Reasonable adult dependent care expenses incurred for any incapacitated or disabled adult in the Medicaid unit are allowed as a deduction from income so a caretaker or spouse can work or attend training. Car Safety Seat The cost to purchase or rent a car safety seat for a child through age 10 is allowed as a deduction if a seat is not otherwise reasonably available. Subsidized Guardianship Payments Disregard subsidized guardianship payments for children. Child and Adult Food Program Disregard payments from the Child and Adult Food Program for meals and snacks to licensed families who provide daycare in their home. Page 54 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Name of income type: Description: Military Personnel Additional Pay Additional pay received by military personnel as a result of deployment to a combat zone is disregarded as income. TANF Cash Grant Disregard TANF cash grant as income. Page 55 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Family Opportunity Act Children with a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-08-002 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 C. Income Standard Used The income standard for this eligibility group is: 1. No income standard (FFP available only for individuals with income at or below 300% FPL) 2. 300% FPL 3. Other percent of FPL 250.00% FPL Page 56 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Family Opportunity Act Children with a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-08-002 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 D. Resource Standard Used There is no resource test for this eligibility group. Page 57 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Family Opportunity Act Children with a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-08-002 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 E. Premiums and Cost Sharing Requirements for premiums and cost sharing for this group are found in the premium and cost sharing sections of the state plan. Page 58 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Family Opportunity Act Children with a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-08-002 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 F. Employer-Based Health Coverage 1. If the eligible individual is offered employer-sponsored coverage under a group health plan, the state requires the parent to apply for, enroll and pay premiums for such coverage, provided that the following conditions are met: a. The parent is eligible for the coverage; and b. The employer contributes at least 50 percent of the total cost of the premiums. 2. Requirements for premium assistance for this group are found in the premium assistance section of the state plan. Page 59 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Family Opportunity Act Children with a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0001O | ND-19-0014 Package Header Package ID ND2019MS0001O Submission Type Official Approval Date 5/13/2020 Superseded SPA ID ND-08-002 User-Entered SPA ID ND-19-0014 Initial Submission Date 9/27/2019 Effective Date 7/1/2019 G. Additional Information (optional) Requirements for premiums and cost sharing for this group are found in the premium and cost sharing sections as well as Attachment 2.6 of the eligibility section of the State Plan. Page 60 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

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 0938-1188. 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. This view was generated on 6/1/2020 10:01 AM EDT Page 61 of 61 Medicaid State Plan Print View 06/01/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: 19- 0016 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages TN: ND- 19- 0016 Approval Date: 11/ 27/2019 Effective Date: 10/ 01/ 2019

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1961 Stout Street, Room 08- 148 Denver, CO 80294 rc ARE& MEDICAID SERVICES Denver Regional Operations Group CENTER FOR MEDICAID& CHIP SERVICES December 2, 2019 Caprice Knapp, Medicaid Director Division of Medical Services North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505- 0250 Dear Ms. Knapp: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number (TN) 19- 0016. This amendment removes copays and other cost-sharing from North Dakota Medicaid' s state plan. This amendment was submitted to bring North Dakota into compliance with statutory and regulatory requirements that limit cost-sharing to a five percent aggregate cap. Because the state was unable to implement a mechanism to track cost sharing and ensure the limit was not exceeded, North Dakota submitted this amendment to remove cost sharing from the state plan. Please be informed that this State Plan Amendment was approved November 27, 2019, with an effective date of October 1, 2019. We are enclosing the CMS- 179 and the amended plan page( s). If you have any questions concerning this amendment, please contact Kirstin Michel at 303) 844- 7036. Sincerely, Mary Marchioni Acting Deputy Division Director Western Regional Operations Group Denver Regional Office Centers for Medicaid and CHIP Services cc: Krista Fremming, North Dakota Stacey Koehly, North Dakota

ND.4739.R00.00 - Oct 01, 2019 Page 1 of 2 Medicaid rmmand Cost Sharin( 14: Surninary Page 7 State/Territory name: North Dakota Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST-YY-0000 where ST=the state abbreviation, YY= the last two digits of the submission rear, and 0000= afour digit number with leading zeros. The dashes must also be entered ll"-- -------- z 19- 0016 uvuvuvuvuvuvuvuvuvuvuvuvuvuvuvuvuvuvuvuvuvuvuvuvuvuvuvv Proposed Effective Date 10/ 0 10/ 01/ 2019 1 ( mm/ dd/ YYYY) Federal Statute/Regulation Citation 342 CFR 447. 30, 447. 32 and 447.56 Federal Budget Impact Federal Fiscal Year Amount First Year 2020 I--------------------------- 1238000. 00 Second Year 12021 1250135. 00 Subject of Amendment Amends the State Plan to remove copayments from the North Dakota Medicaid program. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Ff% s Other, as specified Describe: Authority to prepare and submit Medicaid State Plans is provided to the Single State Medicaid Agency. Submitting this amendment on behalf of Caprice Knapp, ND Medicaid Director, who is authorized to submit Medicaid State Plan Amendments for the State of North Dakota. Signature of State Agency Official Submitted By: Maggie Anderson Last Revision Date: Oct 17, 2019 Submit Date: Sep 30, 2019 https:// wms- mmdl.cros. gov/MMDL/faces/ protected/mpc/f01/ pri... 11/ 26/2019

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: TN-ND- 19- 0016 North Dakota. PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT( IfApp&cable): G- 1 Medicaid Costsharing Attachment 4. 18- A pages 1, la through le; and lh through lq Attachment 4. 18-A pages 1, la through le; and lh through lq Attachment 4. 18- A pages 2 and 3 Attachment 4. 18- A pages 2 and 3 Attachment 4. 18- C pages 1, la through le; and lh through lq Attachment 4. 18- C pages 1, la through le; and lh through lq Attachment 4. 18- C pages 2 and 3 Attachment 4. 18- C pages 2 and 3 Attachments 4. 18- D pages 1 and 2 Attachments 4. 18- D pages 1 and 2 Attachments 4. 18- E pages 1 and 2 Attachments 4. 18- E pages 1 and 2 Pages 54, 55, 56, 56a-f in pre-print section 4. 1 Pages 54, 55, 56, 56a-f in pre-print section 4. 1

w _ Medicaid Premiums and Cast Sharing State Name: North Dakota OMB Control Num Ler- 0938- 1148 Transmittal Number. 19 - 00- 0016 Cost Simi-big Requiremeiits G1 1916 1916A 41-(' I It 44 7. So Lhrough 447.57( excluding 447. 55] The state charges costsharing( deducLil) Its, co- insu ince or co- payments) to individuals covered under Mtdic.sid. ik • PRA DiseloStlre Statorriont According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of infonrration unless it displays a valid OMB wntrol number. The valid ONIM control number for this information collection is 0938- 1148. The time required to complete this information cc) IIcot l0n is cstimatodto ak! crage 40 hours her reshonso, including tho timo to rev icw instructions, search existing data resources, gaL her the data needed, sines compleit and revithe information cc) llect1on. l f y ou hsrve corn menLS con cem1ng the accuracy of the time est IIn rte( s) r suggestions for improving this form, please vvrile Lo: CMS1 7500 Security IlouIevard, Attn:}' RA Iteparts C' lear.ince c] ttieer, lt;fail Stop C4-26- 05. Baltimore, Maryland 21244- 185+). V. 201 60721 NC- 19- 00.1-6 Approva Date: 11/ 27/2319 Effecive Care: 10raifc l5 Page 1 of 1

TN No. 19-0016 Approval Date 11/27/2019 Effective Date 10/01/2019 Supersedes TN No. 17-0008 CMS ID: 0053C/0061E Attachment 4.18-A Revision: CMS-PM-85-14 (BERC) Page 1 September 1985 OMB.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905 (a) (1) through (5) and (7) of the Act: Service Type of Charge Deduct. Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS-PM-85-14 (BERG) Attachment 4.18-A SEPTEMBER 1985 Page 1a OMB No.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins Copay Amount and Basis for Determination VACATED TN NO. 19-0016 Approval Date _11/27/2019______ Effective Date 10/01/2019 Supersedes TN No. 95-008

Revision: CMS-PM-85-14 (BERG) Attachment 4.18-A SEPTEMBER 1985 Page 1b OMB No.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins Copay Amount and Basis for Determination VACATED TN NO. 19-0016 Approval Date _11/27/2019_______ Effective Date 10/01/2019 Supersedes TN No. 95-008

Revision: CMS-PM-85-14 (BERG) SEPTEMBER 1985 Attachment 4.18-A Page 1c 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E section 1905(a)(1) through (5) and (7) ofthe Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E Revision: CMS-PM-85-14 (BERC) SEPTEMBER 1985 Attachment 4.18-A Page 1d 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS-PM-85-14 (BERC} SEPTEMBER 1985 Attachment 4.18-A Page 1e 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E section 1905(a}(1} through (5) and (7) of the Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E Revision: CMS-PM-85-14 (BERG) SEPTEMBER 1985 Attachment 4.18-A Page 1i 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E Revision: CMS-PM-85-14 (BERC) SEPTEMBER 1985 Attachment 4.18-A Page 1j 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E Revision: CMS-PM-85-14 {BERG) SEPTEMBER 1985 Attachment 4.18-A Page 1k 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Deduct Type of Charge Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS-PM-85-14 {BERG). SEPTEMBER 1985 Attachment 4.18-A Page 1l 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS-PM-85-14 (BERC) SEPTEMBER 1985 Attachment 4.18-A Page 1m 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS-PM-85-14 (BERC) SEPTEMBER 1985 Attachment 4.18-A Page 1n 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS-PM-85-14 (BERG) SEPTEMBER 1985 Attachment 4.18-A Page 1o 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS-PM-85-14 (BERG) SEPTEMBER 1Q85 Attachment 4.18-A Page 1p 0MB NO: 0938:-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS-PM-85-14 {BERG) SEPTEMBER 1985 Attachment 4.18-A Page 1h 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED TN No.19-0016 Supersedes TN No.02-021 ApprovalDate 11/27/2019 _ Effective Date 10/01/2019 CMS ID: 0053C/0061E

Revision: CMS-PM-85-14 (BERC) Attachment 4.18-A SEPTEMBER 1985 Page 1q OMB NO: 0938-0193 TN No. 19-0016 Supersedes Approval Date _11/27/2019_________ Effective Date 10/01/2019 TN No. 04-010 CMS ID: 0053C/0061E STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS- PM- 85- 14 ( BERC) SEPTEMBER 1985 ATTACHMENT 4. 18- A Page 2 OMB NO.: 0938- 0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: ________North Dakota______________________ This page intentionally left blank TN No. 19-0016 Supersedes Approval Date_11/ 27/ 2019_______ Effective Date_10/01/2019___ TN No. 93-14

Revision: CMS- PM- 15- 14 ( BERC) SEPTEMBER 1985 ATTACHMENT 4. 18- A Page 3 OMB NO.: 0938- 0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: ________ North Dakota______________________ This page intentionally left blank TN No. 19-0016 Supersedes Approval Date_11/ 27/ 2019_____ Effective Date_10/01/2019___ TN No. 93-14

TN No. 19-0016 Approval Date 11/27/2019 Effective Date 10/01/2019 Supersedes TN No. 17-0008 CMS ID: 0053C/0061E Attachment 4.18-C Revision: CMS-PM-85-14 (BERC) Page 1 September 1985 OMB.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905 (a) (1) through (5) and (7) of the Act: Service Type of Charge Deduct. Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS-PM-85-14 (BERG) Attachment 4.18-C SEPTEMBER 1985 Page 1a OMB No.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins Copay Amount and Basis for Determination VACATED TN NO. 19-0016 Approval Date _11/27/2019_______ Effective Date 10/01/2019 Supersedes TN No. 95-008

Revision: CMS-PM-85-14 (BERG) Attachment 4.18-C SEPTEMBER 1985 Page 1b OMB No.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins Copay Amount and Basis for Determination VACATED TN NO. 19-0016 Approval Date 11/27/2019 Effective Date 10/01/2019 Supersedes TN No. 95-008

Revision: CMS-PM-85-14 (BERG) SEPTEMBER 1985 Attachment 4.18-C Page 1c 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E section 1905(a)(1) through (5) and (7) ofthe Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E Revision: CMS-PM-85-14 (BERC) SEPTEMBER 1985 Attachment 4.18-C Page 1d 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS-PM-85-14 (BERC} SEPTEMBER 1985 Attachment 4.18-C Page 1e 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed onthe categorically needy for services other than those provided under TN No. 19-0016 Supersedes TN No. 03-011 Approval Date Effective Date 10/01/2019 CMS ID: 0053C/0061E section 1905(a}(1} through (5) and (7) of the Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED 11/27/2019

TN No. 19-0016 Supersedes TN No. 03-011 Approval Date Effective Date 10/01/2019 CMS ID: 0053C/0061E Revision: CMS-PM-85-14 (BERG) SEPTEMBER 1985 Attachment 4.18-C Page 1i 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed onthe categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED 11/27/2019

TN No. 19-0016 Supersedes TN No. 03-011 Approval Date Effective Date 10/01/2019 CMS ID: 0053C/0061E Revision: CMS-PM-85-14 (BERC) SEPTEMBER 1985 Attachment 4.18-C Page 1j 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED 11/27/2019

TN No. 19-0016 Supersedes TN No. 03-011 Approval Date Effective Date 10/01/2019 CMS ID: 0053C/0061E Revision: CMS-PM-85-14 {BERG) SEPTEMBER 1985 Attachment 4.18-C Page 1k 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Deduct Type of Charge Coins. Copay. Amount and Basis for Determination VACATED 11/27/2019

Revision: CMS-PM-85-14 {BERG). SEPTEMBER 1985 Attachment 4.18-C Page 1l 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: TN No. 19-0016 Supersedes TN No. 03-011 Approval Date Effective Date 10/01/2019 CMS ID: 0053C/0061E Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED 11/27/2019

Revision: CMS-PM-85-14 (BERC) SEPTEMBER 1985 Attachment 4.18-C Page 1m 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: TN No. 19-0016 Supersedes TN No. 03-011 Approval Date Effective Date 10/01/2019 CMS ID: 0053C/0061E Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED 11/27/2019

Revision: CMS-PM-85-14 (BERC) SEPTEMBER 1985 Attachment 4.18-C Page 1n 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: TN No. 19-0016 Supersedes TN No. 03-011 Approval Date Effective Date 10/01/2019 CMS ID: 0053C/0061E Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED 11/27/2019

Revision: CMS-PM-85-14 (BERG) SEPTEMBER 1985 Attachment 4.18-C Page 1o 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: TN No. 19-0016 Supersedes TN No. 03-011 Approval Date Effective Date 10/01/2019 CMS ID: 0053C/0061E Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED 11/27/2019

Revision: CMS-PM-85-14 (BERG) SEPTEMBER 1Q85 Attachment 4.18-C Page 1p 0MB NO: 0938:-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: TN No. 19-0016 Supersedes TN No. 03-011 Approval Date 11/27/2019 Effective Date 10/01/2019 CMS ID: 0053C/0061E Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS-PM-85-14 {BERG) SEPTEMBER 1985 Attachment 4.18-C Page 1h 0MB NO: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED TN No.19-0016 Supersedes TN No.02-021 ApprovalDate 11/27/2019 _ Effective Date 10/01/2019 CMS ID: 0053C/0061E

Revision: CMS-PM-85-14 (BERC) Attachment 4.18-C SEPTEMBER 1985 Page 1q OMB NO: 0938-0193 TN No. 19-0016 Supersedes Approval Date _11/27/2019______________ Effective Date 10/01/2019 TN No. 04-010 CMS ID: 0053C/0061E STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: North Dakota A. The following charges are imposed on the categorically needy for services other than those provided under section 1905(a)(1) through (5) and (7) of the Act: Service Type of Charge Deduct Coins. Copay. Amount and Basis for Determination VACATED

Revision: CMS- PM- 85- 14 ( BERC) SEPTEMBER 1985 ATTACHMENT 4. 18- C Page 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: ________North Dakota______________________ This page intentionally left blank TN No. 19-0016 Supersedes Approval Date_11/ 27/ 2019________ Effective Date_10/01/2019___ TN No. 93-14

Revision: CMS- PM- 15- 14 ( BERC) SEPTEMBER 1985 ATTACHMENT 4. 18- C Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: ________ North Dakota______________________ This page is intentionally left blank TN No. 19-0016 Supersedes Approval Date_11/ 27/ 2019______ Effective Date_10/01/2019___ TN No. 93-14

Revision: August 1991 CMS-PM-91-4 ( BPD) Attachment 4.18-D Page 1 OMB NO.: 0938- TN No. 19-0016 Supersedes TN No. 93-003 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 7982E State/Territory: North Dakota This page intentionally left blank

Attachment 4.18-D Page 2 OMB NO.: 0938- Revision: August 1991 CMS-PM-91-4 ( BPD) TN No. 19-0016 Supersedes TN No. 93-003 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 7982E State/Territory: North Dakota This page intentionally left blank

Attachment 4.18-E Page 1 Revision: August 1991 CMS-PM-91-4 (BPD) OMB NO.: 0938 TN No. 19-0016 Supersedes TN No. 93-003 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 0053C/0061E State/Territory: North Dakota This page intentionally left blank

Attachment 4.18-E Page 2 OMB NO.: 0938- Revision: August 1991 CMS-PM-91-4 ( BPD) TN No. 19-0016 Supersedes TN No. 93-003 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 7982E State/Territory: North Dakota This page intentionally left blank

54 BPD) Revision: August 1991 CMS-PM-91-4 OMB NO.: 0938- TN No. 19-0016 Supersedes TN No. 93-16 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 7982E State/Territory: North Dakota This page intentionally left blank

55 BPD) Revision: August 1991 CMS-PM-91-4 OMB NO.: 0938- TN No. 19-0016 Supersedes TN No. 03-018 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 7982E State/Territory: North Dakota This page intentionally left blank

56 Revision: August 1991 CMS-PM-91-4 (BPD) OMB NO.: 0938 State/Territory: North Dakota TN No. 19-0016 Supersedes TN No. 93-16 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 0053C/0061E This page intentionally left blank

56a Revision: August 1991 CMS-PM-91-4 (BPD) OMB NO.: 0938 State/Territory: North Dakota TN No. 19-0016 Supersedes TN No. 92-09 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 7982E This page intentionally left blank

56b Revision: August 1991 CMS-PM-91-4 (BPD) OMB NO.: 0938 State/Territory: North Dakota TN No. 19-0016 Supersedes TN No. 92-09 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 7982E This page intentionally left blank

56c Revision: August 1991 CMS-PM-91-4 (BPD) OMB NO.: 0938 State/Territory: North Dakota TN No. 19-0016 Supersedes TN No. 93-16 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 7982E This page intentionally left blank

56d Revision: August 1991 CMS-PM-91-4 (BPD) OMB NO.: 0938 State/Territory: North Dakota TN No. 19-0016 Supersedes TN No. 92-09 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 7982E This page intentionally left blank

56e Revision: August 1991 CMS-PM-91-4 (BPD) OMB NO.: 0938 State/Territory: North Dakota TN No. 19-0016 Supersedes TN No. 93-16 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 7982E This page intentionally left blank

56f Revision: August 1991 CMS-PM-91-4 (BPD) OMB NO.: 0938 State/Territory: North Dakota TN No. 19-0016 Supersedes TN No. 92-09 Approval Date 11/27/2019 Effective Date: 10/01/2019 CMS ID: 7982E This page is intentionally left blank

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Table of Contents

State/Territory Name: North Dakota State Plan Amendment (SPA) #: 19-0017 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages

TN: ND-19-0017 Approval Date: 8/17/20

Effective Date: 08/01/2019

Records / Submission Packages - View All ND - Submission Package - ND2019MS0004O - (ND-19-0017) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID ND2019MS0004O Program Name N/A SPA ID ND-19-0017 Version Number 4 Submitted By LeeAnn Thiel Package Disposition Priority Code P2 Submission Type OŰcial State ND Region Denver, CO Package Status Approved Submission Date 9/30/2019 Approval Date 8/17/2020 12:14 PM EDT Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter RAI Transaction Logs News Related Actions

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid & CHIP Operations Group 601 E. 12th Street, Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services August 17, 2020 Christopher Jones Executive Director ND Medical Services Dept 325 600 E Boulevard Ave Bismarck, ND 58505 Re: Approval of State Plan Amendment ND-19-0017 Dear Christopher Jones: On September 30, 2019, the Centers for Medicare and Medicaid Services (CMS) received North Dakota State Plan Amendment (SPA) ND-19-0017 to amend the State Plan to remove the $6000 limit on burial accounts eſective August 1, 2019 and amends the State Plan language to be consistent with federal law for annuities. This amendment resolves the companion letter issued with the approval of ND TN 18- 0015. We approve North Dakota State Plan Amendment (SPA) ND-19-0017 on August 17, 2020 with an eſective date(s) of August 01, 2019. Name Date Created No items available If you have any questions regarding this amendment, please contact Curtis Volesky at curtis.volesky@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services RAI CMS is issuing this Request for Additional Information (RAI) pursuant to Section 1915(f) of the Social Security Act (added by P.L. 97-35). This request has the eſect of stopping the 90-day time period for CMS to act on the material. A new 90 day time frame will not begin until we receive your response to this request.In accordance with our guidelines to all State Medicaid directors dated January 2, 2001, and subsequently reiterated in the August 16, 2018 Center for Medicaid and CHIP Services Informational Bulletin, if a response to a formal request for additional information from CMS is not received from the state within 90 days of issuance, CMS will initiate disapproval of the SPA or waiver action. In addition, because this amendment was submitted after January 2, 2001 and is eſective after January 1, 2001, please be advised that we will defer federal ţnancial participation (FFP) for state payments made in

accordance with this amendment until it is approved. Upon approval, FFP will be available for the period beginning with the eſective date through the date of approval. Submission Package ND2019MS0004O Authority Eligibility State ND Agency Name ND Medical Services Submission Date Sep 30, 2019 Priority Code P2 All Questions Question ID Reference CMS question to the State Policy/Regulation State Response 1 Missing eligibility groups Pursuant to the authority provided by section 1902(r)(2) of the Social Security Act (the Act), North Dakota has elected to apply less restrictive income and resource methodologies to eligibility groups exempt from MAGI methodologies. Based on information contained in North Dakota’s existing state plan pages, it applies these less restrictive methodologies to eligibility groups that were not included in the reviewable units in this SPA. In order to complete our review, the state must include all eligibility groups to which the less restrictive income and resource methodologies apply, and include in those reviewable units the description of all the methodologies that apply to each group. Section 1902(r)(2) of the Social Security Act The applicable reviewable units have been added to this SPA.

Question ID Reference CMS question to the State Policy/Regulation State Response 2 1. Supplement 4 to Attachment 2.6- A, Methods for Treatment of Income that Diſer from Those of the SSI Program: a. Item #2: Regarding self- employment, is it North Dakota’s policy to allow net losses from self- employment to only oſset the net gains from self-employment instead of oſsetting other earned income? (See the Social Security Administration’s Program Operations Manual System (POMS) SI 00820.210 for review of the relevant SSI policy.) b. Item #3: Regarding income from the rental of rooms, apartments, or other property, the state considers this to be earned income and SSI methodologies employ a general earned income disregard. Does North Dakota apply a methodology that is more restrictive or less restrictive? c. Item #5: Regarding veterans’ beneţts, because the state conţrmed that there are no state-based veterans’ beneţts during our November 25, 2019 call, CMS believes this section should be removed because it appears North Dakota’s policy is aligned with SSI’s veteran beneţt policies, as described in POMS SI 00830.260-317. Can the State identify a more restrictive methodology for this type of income? d. Item #6: Regarding non-recurring lump sum income, is it the State’s policy to count the entire non- recurring lump sum an individual receives without applying any exclusions? e. Deţnition of Terms, Item #1: Under deţnition of terms (ineligible medical assistance unit), North Dakota deţnes “ineligible medical assistance unit.” Is this the deţnition that North Dakota presently utilizes for the more restrictive methodology listed on page 1 of Supplement 4 and for the calculation of an individual’s income when the individual’s Medicaid eligibility is being evaluated? Section 1902(f) of the Social Security Act a. North Dakota’s policy is to allow net losses from self-employment to only oſset net gains. b. Yes, North Dakota’s policy is a more restrictive methodology. c. North Dakota does have programs that beneţt veterans that do not meet the requirements of POMS SI 00830.260-317. POMS SI 00830.260- 317 only refers to state annuities. d. North Dakota’s policy is apply certain income disregards. e. North Dakota uses the deţnition of “ineligible medical assistance unit” on Page 1a of Supplement 4 to Attachment 2.6-A for the more restrictive criteria identiţed on Page 1 of Supplement 4 to Attachment 2.6-A. A specialized facility is not an institution and is deţned in North Dakota Administrative Code 75-02- 02.1-01(33).

Question ID Reference CMS question to the State Policy/Regulation State Response 3 2. Supplement 5 to Attachment 2.6- A, More Restrictive Methods of Treating Resources than those of the SSI Program a. Item #1: Regarding parental and spousal resources, does the State consider the resources of an individual residing in the community when the individual’s institutionalized spouse’s Medicaid is being evaluated? If this does reŤect current state practice, please remove the second sentence of this methodology as it is in conŤict with section 1924 of the Act. b. Item #2: Regarding the resource calculation for spouses who are living apart (one spouse in an institution), how does North Dakota’s current policy compare to Medicaid’s deeming regulations described at 42 CFR 435.602(a)(2)(iii) and (iv)? When one spouse is institutionalized, the spousal impoverishment provisions described at Section 1924 of the Act are triggered. These provisions specify that states may not allocate the income or resources of the community spouse to the spouse who resides in the institution. If State policy is diſerent from these requirements, this methodology should be deleted because nothing in Section 1902(f) of the Act)—which provides the authority for more restrictive ţnancial methodologies and creates the 209(b) status—supersedes the provisions of Section 1924. c. Item #4: Regarding liquid assets, how is North Dakota’s policy diſerent from that of the SSI program? (See SI 01110.300-310.) d. Item 10: Regarding funeral set- asides, is the limit for the set-aside North Dakota describes in its state plan $3,500 or $5,000? e. Item 12: Regarding an automobile or other personal vehicle, is it North Dakota’s policy to only exclude the vehicle if it is used to serve the needs of the members of the Medicaid unit? (See POMS SI 01130.200 for SSI’s automobile policy.) Section 1902(f) of the Social Security Act a. a. A specialized facility is not an institution and is deţned in North Dakota Administrative Code 75-02- 02.1-01(33). b. North Dakota policy does not allow income or assets from the ineligible community spouse to be deemed to the eligible, institutionalized spouse (except for up to $65 per month for the personal needs allowance, if the institutionalized spouse has no income). c. North Dakota’s policy is more restrictive because we do not apply the 20 workdays limit for converting a liquid asset to cash that SSI uses. d. North Dakota currently has an open SPA for funeral set asides. The limit will be addressed with TN 19- 0012. e. Yes. Submission Package was updated by the State in accordance with the response above Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Yes No

Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID N/A SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date N/A State Information State/Territory Name: North Dakota Medicaid Agency Name: ND Medical Services Submission Component State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID N/A SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date N/A SPA ID and Eſective Date SPA ID ND-19-0017 Reviewable Unit Proposed Eſective Date Superseded SPA ID Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability 8/1/2019 ND-19-0014 More Restrictive Requirements than SSI under 1902(f) - (209(b) States) 8/1/2019 ND-19-0014 Medically Needy Income Level 8/1/2019 ND 03-005 Medically Needy Resource Level 8/1/2019 ND 92-010 Mandatory Eligibility Groups 8/1/2019 ND-19-0014 Individuals in 209(b) States Who Are Age 65 or Older or Who have Blindness or a Disability 8/1/2019 ND-19-0014 Qualiţed Medicare Beneţciaries 8/1/2019 ND-10-0002 Speciţed Low Income Medicare Beneţciaries 8/1/2019 ND-10-0002 Qualifying Individuals 8/1/2019 ND-10-0002 Optional Eligibility Groups 8/1/2019 ND-19-0014 Ticket to Work Basic 8/1/2019 ND-10-0002 Medically Needy Pregnant Women 8/1/2019 ND-10-0002 Medically Needy Children under Age 18 8/1/2019 ND-10-0002 Medically Needy Reasonable Classiţcations of Individuals under Age 21 8/1/2019 ND-10-0002 Medically Needy Parents and Other Caretaker Relatives 8/1/2019 ND-10-0002 Medically Needy Populations Based on Age, Blindness or Disability 8/1/2019 ND-10-0002 Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID N/A SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives Amends the State Plan to remove the $6000 limit on burial accounts eſective August 1, 2019 and amends the State Plan language to be consistent with federal law for annuities. This amendment resolves the companion letter issued with the approval of ND TN 18-0015. North Dakota also updated ND Century Code (50-24.1-02.8) during the 2019 Legislative Assembly to ensure state statute was consistent with federal law https://www.legis.nd.gov/assembly/66-2019/documents/19-8087-04000.pdf Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2019 $41147 Second 2020 $165734 Federal Statute / Regulation Citation 1902(r)(2) of the Act Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID N/A SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date N/A Governor's OŰce Review Describe Authority to prepare and submit Medicaid State Plans is provided to the Medicaid Single State agency. No comment Comments received No response within 45 days Other

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID N/A SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date N/A Indicate whether public comment was solicited with respect to this submission. Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID N/A SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state This state plan amendment is likely to have a direct eſect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Explain why this SPA is not likely to have a direct eſect on Indians, Indian Health Programs or Urban Indian Organizations: This SPA is only aligning the language to federal law. Yes No Yes No

Medicaid State Plan Eligibility Income/Resource Methodologies Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a Disability Eligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following: The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneţciaries. For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, the state requires a separate Medicaid application and determines ţnancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneţciaries, to ţle a separate Medicaid application, and determines ţnancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneţciaries, to ţle a separate Medicaid application, and determines ţnancial eligibility using income and resource methodologies more restrictive than SSI. B. Additional information (optional) 1. SSA Eligibility Determination State (1634 State) 2. State Eligibility Determination (SSI Criteria State) 3. State Eligibility Determination (209(b) State)

Medicaid State Plan Eligibility Income/Resource Methodologies More Restrictive Requirements than SSI under 1902(f) - (209(b) States) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 The state applies more restrictive requirements than SSI under the authority of section 1902(f) of the Act, and consistent with 42 CFR 435.121. A. Use of More Restrictive Requirements The state applies more restrictive eligibility requirements to individuals who are age 65 or older or who have blindness or disability. The more restrictive requirements are no more restrictive than those requirements contained in the state's Medicaid plan in eſect on January 1, 1972. The state does not apply more restrictive requirements if: 1. The requirement conŤicts with the requirements of section 1924 of the Act, which governs the eligibility and post-eligibility treatment of income and resources of institutionalized individuals with community spouses; 2. The requirement conŤicts with a more liberal requirement which the agency has elected to use under 42 CFR 435.601; or 3. The more restrictive requirement conŤicts with a more liberal requirement the state has elected to use under §435.234(c) in determining eligibility for State supplementary payments. B. Populations with More Restrictive Requirements The state applies more restrictive requirements for the following populations: C. Types of More Restrictive Requirements Used The state applies more restrictive requirements for the following populations: 1. Individuals age 65 or older 2. Individuals who have blindness 3. Individuals who have a disability 1. The state uses more restrictive requirements with respect to income. 2. The state uses more restrictive requirements with respect to resources. 3. The state uses more restrictive requirements with respect to the deţnition of disability. 4. The state uses more restrictive requirements with respect to the deţnition of blindness. 5. The state uses more restrictive requirements with respect to ţnancial responsibility of relatives.

6. The state uses other more restrictive requirements.

More Restrictive Requirements than SSI under 1902(f) - (209(b) States) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 D. More Restrictive Requirements with Respect to Income The following more restrictive requirements are used with respect to income: Description: No income from any other source may be used to oſset a self-employment loss. Description: All infrequent or irregular income is considered in the month received. Name of requirement: Description: Ineligible Medical Assistance Unit Twenty-ţve percent of that excess income of the ineligible medical assistance unit in the home which exceeds the appropriate medically needy income level will be deemed to be available to an eligible individual residing in a specialized facility Unearned Income Income from rental of rooms, apartments, or other property is unearned income, except that income from room rentals is considered "earned," if the recipient is actively engaged in the venture by such means as making the bed, changing linens, cleaning the room, etc. Veterans Beneţts All veterans beneţts (except Aid and Attendance) are considered non-exempt income for the Aged, Blind and Disabled. Lump Sum Income Non-recurring lump sum income is considered income in the month received and a resource thereafter except retroactive lump sum SSI payments which are disregarded in the month received. 1. The state uses a lower income standard than the SSI or the Optional State Supplement standard for eligibility groups under Mandatory Coverage and Options for Coverage. 2. The state uses more restrictive income disregards or exclusions. 3. The state uses more restrictive requirements with respect to income from self employment. 4. The state uses more restrictive requirements with respect to irregular/infrequent income. 5. The state uses other more restrictive requirements with respect to income:

More Restrictive Requirements than SSI under 1902(f) - (209(b) States) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 E. More Restrictive Requirements with Respect to Resources The following more restrictive requirements are used with respect to resources: Name of requirement: Description: Joint Ownership Real Property includes land, buildings, mineral rights, burial plots, contractual rights on real property, etc. Joint ownership of real property will be considered available on an equal basis unless otherwise speciţed. Description: Retroactive lump-sum SSI income payments are counted as resources in the month following the month in which they are received. Description: Personal property includes cash surrender value of life insurance policies, vehicles, machinery, livestock, grave markers, burial vaults, contractual rights on personal property, etc. Joint ownership of personal property will be considered available on an equal basis unless otherwise speciţed. Name of requirement: Description: 1. The state uses a lower resource standard than the SSI or the Optional State Supplement standard for eligibility groups under Mandatory Coverage and Options for Coverage. 2. The state uses more restrictive requirements with respect to the treatment of real property. a. The state uses a more restrictive requirement with respect to the treatment of home property. b. The state uses other more restrictive requirements related to real property. 3. The state uses more restrictive requirements with respect to the treatment of lump sums. 4. The state uses more restrictive requirements with respect to the treatment of personal property. 5. The state uses other more restrictive requirements with respect to resources:

Name of requirement: Description: Contract for Deed The essential feature of a " Contract for Deed" is the right to receive periodic payments, usually coupled with a right to get the property back if the payments are not made. Contractual rights to receive monthly payments also arise out of other types of transactions. The valuable contract documents may be called a note, accounts receivable, mortgage, or by some other name.

Because many such contracts were entered into when interest rates were lower, the contracts are not negotiable at their face value. That is not to say they have no value. A proper valuation may be made by a process called " discounting", which will take into account the changes in the interest rates. The discounted value will be determined by the Legal Services Division of the Department of Human Services. A letter requesting the discounted value accompanied by the contract documents must be sent to the Legal Services Division.

If the discounted value, alone or added to the value of other property, is in excess of program limits, the applicant/recipient is ineligible and may attempt to reduce property holdings to the allowable resource limits to establish eligibility. It is presumed that the contract, like any other property, is saleable without working an undue hardship. Personal Vehicle When one automobile or other personal vehicle is not exempt, because its primary purpose is not to serve the needs of members of the Medicaid unit, the entire value of the vehicle is counted as an asset.

Name of requirement: Description: Resource Exemptions The home occupied by the individual or member of the Medical Assistance Unit will be exempt in determining eligibility for Medical Assistance. The home is deţned as including the land on which it is located, providing the acreage does not exceed 160 contiguous acres if rural, or two acres if located in town. Acreage in excess of the 160 rural) or 2 ( if located in town) would be declared " Real Property Other Than the Home."

The home will be considered "occupied" and exempt if the individual or Medical Assistance Unit is temporarily absent but actually intends, and is able, to return within a reasonable length of time; otherwise such property will be considered " Other Real Property." If the home is exempt for the aforementioned reason, adequate documentation and frequent review are required.

The home of an individual in long term care or the State Hospital with no spouse or family at home may be considered exempt for a period of not more than six months when a physician has certiţed that the individual is likely to return to his home within that period. Parent Resources Except for individuals covered by Section 1924 of the Act, the resources of the parent( s) will be deemed available for those individuals who are in long term care, the State Hospital, or in a specialized facility and thus considered separated for purposes of the SSI Program. The resources of the spouse will be deemed available for these individuals who are in a specialized facility and thus considered separated for the purposes of the SSI Program. The medically needy resource provisions will be applied as though the individual( s) were all residing in the same household. Noninstitutionalized Spouse Except for individuals covered by Section 1924 of the Act, the ineligible, noninstitutionalized spouse who has lived apart from the applicant or recipient for at least six months may separately own resources ( liquid, personal or real) up to the maximum amount allowed. Income Producing Property All SSI recipients are subject to the medically needy resource limit regarding income producing property.

Name of requirement: Description: Liquid Assets Liquid assets include actual cash, savings, redeemable stocks and bonds, accounts receivable, etc. Liquid assets can be replenished at any time and may be accumulated out of exempted income during periods of eligibility. Liquid assets held in joint ownership will be considered available in total to the Medical Assistance Unit. Burial Insurance Burial insurance is counted unless it speciţcally provides that the proceeds can be used only to pay burial expenses of the insured. Available Property Real or personal property which is essential to earning a livelihood is considered " available" in determining Medical Assistance eligibility unless the property owners are actively engaged in using the property to earn income and derive the total beneţt of such income for their personal needs. An individual is actively engaged in utilizing the property if the individual contributes signiţcant current personal labor in utilizing the property for income producing purposes. The payment of social security taxes on the income from such current personal labor is an indicator of the active utilization of the property. ( Property which merely produces rental or lease income will be considered available in determining Medical Assistance eligibility.)

More Restrictive Requirements than SSI under 1902(f) - (209(b) States) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 J. Income Deductions When applying more restrictive requirements, the state deducts SSI payments received by the individual and state supplement payments that meet the conditions speciţed in 42 CFR 435.232 and 435.234. The state also allows the following individuals to deduct incurred medical and remedial expenses (spend down) to become categorically eligible under the group for individuals in 209(b) states who are age 65 or over or who have blindness or a disability: 1. SSI beneţciaries and eligible spouses of SSI beneţciaries 2. State supplement recipients or individuals who are eligible for but not receiving a state supplementary payment. 3. Individuals who would be eligible for SSI/SSP but for OASDI COLA increases since April, 1977 (42 CFR 435.135) In determining countable income used for the purpose of calculating spend down for this population, the state deducts OADSI beneţts, as follows: 4. Disabled widows and widowers ineligible for SSI due to increase in OASDI (42 CFR 435.137) In determining countable income used for the purpose of calculating spend down for this population, the state deducts OADSI beneţts, as follows: 5. Disabled widows and widowers ineligible for SSI due to early receipt of social security (42 CFR 435.138) In determining countable income used for the purpose of calculating spend down for this population, the state deducts OADSI beneţts, as follows: 6. Adult children with disabilities (1939(a)(2)(D) and 1634(c) of the Act) In determining countable income used for the purpose of calculating spend down for this population, the state deducts OASDI beneţts, as follows: a. All of the OASDI beneţts is deducted from income. b. Part of the OASDI beneţts is deducted from income. c. None of the OASDI beneţts is deducted from income. a. All of the OASDI beneţts is deducted from income. b. Part of the OASDI beneţts is deducted from income. c. None of the OASDI beneţts is deducted from income. a. All of the OASDI beneţts is deducted from income. b. Part of the OASDI beneţts is deducted from income. c. None of the OASDI beneţts is deducted from income. a. All of the OASDI beneţts is deducted from income. b. Part of the OASDI beneţts is deducted from income. c. None of the OASDI beneţts is deducted from income.

More Restrictive Requirements than SSI under 1902(f) - (209(b) States) MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 K. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND 03-005 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 A. Income Level Used 1. The state employs a single income level for the medically needy, subject to the condition described in A.3. 2. The income level varies based on diſerences between shelter costs in urban and rural areas. 3. The state has a separate income level for the individuals who are age 65 or older, or who have blindness or a disability. 4. The level used is: Household size Standard 5 $908.00 6 $1008.00 7 $1083.00 8 $1141.00 9 $1200.00 10 $1250.00 1 $500.00 2 $516.00 3 $666.00 4 $800.00 The state uses an additional incremental amount for larger household sizes. Incremental Amount: $57.00 The dollar amounts increase automatically each year Yes No Yes No Yes No Yes No

Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND 03-005 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Basis for Income Level 1. Minimum Income Level The minimum income level for this eligibility group is the lower of the state’s July 1996 AFDC payment standard or the state’s income standard for the Parents and Other Caretaker Relatives eligibility group. 2. Maximum Income Level The maximum income level for this eligibility group is 133 1/3 percent of the higher of the state's 1996 AFDC payment standard or the state's income standard for the Parents and Other Caretaker Relatives eligibility group.

Medically Needy Income Level MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND 03-005 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Additional Information (optional)

Medicaid State Plan Eligibility Income/Resource Standards Medically Needy Resource Level MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND 92-010 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 A. Medically Needy Resource Level Structure 1. The state employs a single resource level for the medically needy, subject to the condition described in A.3. 2. The resource level is equal to or higher than the lowest resource standard used under the most closely related cash assistance program. 3. The state has a separate resource level for the individuals who are age 65 or older, or who have blindness or a disability that is more restrictive than the resource level used for other medically needy populations. Yes No

Medically Needy Resource Level MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND 92-010 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Resource Level Used The level used is: Household size Standard 1 $3000.00 2 $6000.00 The state uses an additional incremental amount for larger household sizes. Incremental Amount: $25.00 Yes No

Medically Needy Resource Level MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND 92-010 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Additional Information (optional)

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children NEW Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals in 209(b) States Who Are Age 65 or Older or Who have Blindness or a Disability APPROVED

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

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group CONVERTED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A Yes No

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Individuals in 209(b) States Who Are Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 In 209(b) states, individuals who are 65 or older or who have blindness or a disability, who meet more restrictive criteria than used in SSI Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 The state covers the mandatory eligibility group for individuals in 209(b) states who are age 65 or older or who have blindness or a disability in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Be age 65 or older or have blindness or a disability; 2. Meet more restrictive requirements than SSI, as deţned by the state in section B; 3. Have income and resources at or below the standard for this group.

Individuals in 209(b) States Who Are Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Financial Methodologies 1. The more restrictive requirements used are described in the More Restrictive Requirements than SSI under 1902(f) RU. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: Guardian or Conservator The legally appointed guardian or conservator may be allowed to retain 5 percent of a recipient's monthly beneţts as reimbursement for services. The remainder of the recipient's monthly beneţt shall be considered available to the Medical Assistance Unit. Amount: $25.00 Description of disregard: The ţrst $25 of unearned income from rental of rooms, apartments, or other property from each unit is exempt to defray any associated expenses. Description of disregard: All wages paid by the Census Bureau for temporary employment related to census activities are excluded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: For each individual who is not an aged, blind, or disabled recipient within a family who is employed or in training, deduct the $30 standard work/ training expense allowance. Yes No General income disregard: A speciţed amount of unearned income is disregarded. Census Bureau wages are disregarded. Interest is disregarded. Dividends are disregarded. Training allowances and expenses are disregarded. A speciţed type of income is disregarded:

Name of income type: Description: Name of income type: Description: Income In-Kind Income in- kind is to be excluded except that income in-kind which is in lieu of wages is considered earned income. Extra Checks of Earned or Unearned Income Extra checks of earned or unearned income received from a regularly recurring income source are disregarded as income. Bonus checks, or checks for any other reason, are not considered extra checks. The last check received in the month is considered the extra check. Child Care Costs Allow reasonable child care costs necessary for employment or training to be deducted from income. Payroll Deductions and Union Dues Gross earnings for employed individuals who are not aged, blind, or disabled applicants or recipients are reduced by mandatory payroll deductions and union dues actually withheld or actually paid or $90 whichever is greater. Child Support The First $50 per month of current child support, received on behalf of children in the Medicaid unit, will be disregarded from each budget unit that is budgeted with a separate income level. Adult Dependent Care Expenses Reasonable adult dependent care expenses incurred for any incapacitated or disabled adult in the Medicaid unit are allowed as a deduction from income so a caretaker or spouse can work or attend training. Car Safety Seat The cost to purchase or rent a car safety seat for a child through age 10 is allowed as a deduction if a seat is not otherwise reasonably available. Subsidized Guardianship Payments Disregard subsidized guardianship payments for children. Child and Adult Food Program Disregard payments from the Child and Adult Food Program for meals and snacks to licensed families who provide daycare in their home. Military Personnel Additional Pay Additional pay received by military personnel as a result of deployment to a combat zone is disregarded as income. TANF Cash Grant Disregard TANF cash grant as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Yes No

Name of resource type: Description: Salability of "Contractual Rights to Receive Payment" An applicant/recipient may rebut the presumption of the salability of "contractual rights to receive payment" by showing the following. a. That his interest in the contract was advertised for sale in a newspaper whose circulation area includes the area where the real property relating to the contract is located. This advertisement must be published successively for two weeks if the newspaper is a weekly and for one week if it is a daily. b.The sworn statement of the applicant/ recipient that no oſers were received which equaled or exceeded the minimum price. If all oſers were below the minimum price, the property is determined to be not saleable; any oſer received that is equal to or in excess of the minimum price will establish that the property is saleable and the seller has the right to accept any of the oſers. Rebuttals must be made immediately prior to each redetermination of eligibility for the property to continue to be treated as unsalable. Eſective Date of Eligibility Eſective Date of Eligibility - An individual is considered resource eligible for the full month if he/she attains resource eligibility on any day of the month, without regard to whether the individual was resource eligible on the ţrst moment of the ţrst day of the month. Life Estate Eſective July 1, 1996 the value of a life estate will be excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Value of Mineral Acres The value of mineral acres are excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Employee Beneţt Annuity The value of an employee beneţt annuity that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simpliţed employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in § 408 of the Internal Revenue Code of 1986 is excluded. A speciţed type of resource is disregarded:

Name of resource type: Description: State Tax Refunds State tax refunds and refundable tax credits are excluded as resources for nine months beginning after the month of receipt. Real or Personal Property Real or personal property which is not saleable without working an undue hardship may be considered unavailable in determining Medical Assistance eligibility. Property which has been, in good faith, oſered for sale, and for which no oſer has been received which equals or exceeds 75% of the reasonable market value, will normally be treated as not saleable without working an undue hardship. A good faith oſer to sell real property would normally include advertisements and listings with real estate agents or local dealers in real estate. The reasonable market value of real property may be established by appraisal or by any other method which is likely to produce an accurate valuation. Valuations established for real estate tax purposes shall not be used. A good faith oſer to sell personal property would normally include advertisements, listing with real estate agents or local dealers. The reasonable market value of personal property may be established by appraisals or by any other method which is likely to produce an accurate valuation. Resource Standards Disregard countable resources, for single individuals, between $2,000 and $3,000, and, for couples (or 2-person households), between $3,000 and $6,000 (+$25 for each additional individual). A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Individuals in 209(b) States Who Are Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Income Standard Used The income standard for this group is: Statewide standard The statewide standard is: Household size Standard 1 $500.00 2 $516.00 3 $666.00 4 $800.00 5 $908.00 6 $1008.00 7 $1083.00 8 $1141.00 9 $1200.00 10 $1250.00 The state uses an additional incremental amount for larger household sizes. Incremental Amount $57.00 The dollar amounts increase automatically each year 1. A percentage of the federal poverty level: 2. A dollar amount 3. Another standard Yes No Yes No

Individuals in 209(b) States Who Are Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 D. Resource Standard Used The resource standard for this group is: Individual: $2000.00 Couple: $3000.00

Individuals in 209(b) States Who Are Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 E. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is deţned in the Handling of Excess Income (Spenddown) RU.

Individuals in 209(b) States Who Are Age 65 or Older or Who Have Blindness or a Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Qualiţed Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Individuals with income equal to or less than 100% of the FPL, who are entitled to Medicare Part A, and who qualify for Medicare cost-sharing. Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 The state covers the mandatory qualiţed Medicare beneţciaries group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are entitled to hospital insurance beneţts under part A of title XVIII (Medicare Part A), including individuals who have purchased a premium to enroll in Part A.

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

Qualiţed Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: Guardian or Conservator The legally appointed guardian or conservator may be allowed to retain 5 percent of a recipient's monthly beneţts as reimbursement for services. The remainder of the recipient's monthly beneţt shall be considered available to the Medical Assistance Unit. Amount: $25.00 Description of disregard: The ţrst $25 of unearned income from rental of rooms, apartments, or other property from each unit is exempt to defray any associated expenses. Description of disregard: All wages paid by the Census Bureau for temporary employment related to census activities are excluded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: For each individual who is not an aged, blind, or disabled recipient within a family who is employed or in training, deduct the $30 standard work/ training expense allowance. Yes No General income disregard: A speciţed amount of unearned income is disregarded. Census Bureau wages are disregarded. Interest is disregarded. Dividends are disregarded. Training allowances and expenses are disregarded. A speciţed type of income is disregarded:

Name of income type: Description: Name of income type: Description: Extra Checks of Earned or Unearned Income Extra checks of earned or unearned income received from a regularly recurring income source are disregarded as income. Bonus checks, or checks for any other reason, are not considered extra checks. The last check received in the month is considered the extra check. Child Care Costs Allow reasonable child care costs necessary for employment or training to be deducted from income. Payroll Deductions and Union Dues Gross earnings for employed individuals who are not aged, blind, or disabled applicants or recipients are reduced by mandatory payroll deductions and union dues actually withheld or actually paid or $90 whichever is greater. Child Support The First $50 per month of current child support, received on behalf of children in the Medicaid unit, will be disregarded from each budget unit that is budgeted with a separate income level. Adult Dependent Care Expenses Reasonable adult dependent care expenses incurred for any incapacitated or disabled adult in the Medicaid unit are allowed as a deduction from income so a caretaker or spouse can work or attend training. Car Safety Seat The cost to purchase or rent a car safety seat for a child through age 10 is allowed as a deduction if a seat is not otherwise reasonably available. Income In-Kind Income in- kind is to be excluded except that income in-kind which is in lieu of wages is considered earned income. Subsidized Guardianship Payments Disregard subsidized guardianship payments for children. Child and Adult Food Program Disregard payments from the Child and Adult Food Program for meals and snacks to licensed families who provide daycare in their home. Military Personnel Additional Pay Additional pay received by military personnel as a result of deployment to a combat zone is disregarded as income. TANF Cash Grant Disregard TANF cash grant as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Yes No

Name of resource type: Description: Salability of "Contractual Rights to Receive Payment" An applicant/recipient may rebut the presumption of the salability of "contractual rights to receive payment" by showing the following. a. That his interest in the contract was advertised for sale in a newspaper whose circulation area includes the area where the real property relating to the contract is located. This advertisement must be published successively for two weeks if the newspaper is a weekly and for one week if it is a daily. b.The sworn statement of the applicant/ recipient that no oſers were received which equaled or exceeded the minimum price. If all oſers were below the minimum price, the property is determined to be not saleable; any oſer received that is equal to or in excess of the minimum price will establish that the property is saleable and the seller has the right to accept any of the oſers. Rebuttals must be made immediately prior to each redetermination of eligibility for the property to continue to be treated as unsalable. Eſective Date of Eligibility Eſective Date of Eligibility - An individual is considered resource eligible for the full month if he/she attains resource eligibility on any day of the month, without regard to whether the individual was resource eligible on the ţrst moment of the ţrst day of the month. Life Estate Eſective July 1, 1996 the value of a life estate will be excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Value of Mineral Acres The value of mineral acres are excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Employee Beneţt Annuity The value of an employee beneţt annuity that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simpliţed employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in § 408 of the Internal Revenue Code of 1986 is excluded. A speciţed type of resource is disregarded:

Name of resource type: Description: State Tax Refunds State tax refunds and refundable tax credits are excluded as resources for nine months beginning after the month of receipt. Real or Personal Property Real or personal property which is not saleable without working an undue hardship may be considered unavailable in determining Medical Assistance eligibility. Property which has been, in good faith, oſered for sale, and for which no oſer has been received which equals or exceeds 75% of the reasonable market value, will normally be treated as not saleable without working an undue hardship. A good faith oſer to sell real property would normally include advertisements and listings with real estate agents or local dealers in real estate. The reasonable market value of real property may be established by appraisal or by any other method which is likely to produce an accurate valuation. Valuations established for real estate tax purposes shall not be used. A good faith oſer to sell personal property would normally include advertisements, listing with real estate agents or local dealers. The reasonable market value of personal property may be established by appraisals or by any other method which is likely to produce an accurate valuation. A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Qualiţed Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Income Standard Used The amount of the income standard for this group is 100% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-beneţt low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment of co-insurance and deductibles for Medicare Parts A, B and C and payment for the premiums for Medicare Parts A and B.

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

Qualiţed Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Speciţed Low Income Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Individuals with income above 100% and below 120% of the FPL who are entitled to Medicare Part A, who qualify for payment of Medicare Part B premiums. Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 The state covers the mandatory speciţed low income Medicare beneţciaries group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Would qualify as Qualiţed Medicare Beneţciaries (described in section 1905(p)(1) of the Act), except that their income exceeds the income level for that eligibility group.

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

Speciţed Low Income Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: Guardian or Conservator The legally appointed guardian or conservator may be allowed to retain 5 percent of a recipient's monthly beneţts as reimbursement for services. The remainder of the recipient's monthly beneţt shall be considered available to the Medical Assistance Unit. Amount: $25.00 Description of disregard: The ţrst $25 of unearned income from rental of rooms, apartments, or other property from each unit is exempt to defray any associated expenses. Description of disregard: All wages paid by the Census Bureau for temporary employment related to census activities are excluded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: For each individual who is not an aged, blind, or disabled recipient within a family who is employed or in training, deduct the $30 standard work/ training expense allowance. Yes No General income disregard: A speciţed amount of unearned income is disregarded. Census Bureau wages are disregarded. Interest is disregarded. Dividends are disregarded. Training allowances and expenses are disregarded. A speciţed type of income is disregarded:

Name of income type: Description: Name of income type: Description: Income In-Kind Income in- kind is to be excluded except that income in-kind which is in lieu of wages is considered earned income. Extra Checks of Earned or Unearned Income Extra checks of earned or unearned income received from a regularly recurring income source are disregarded as income. Bonus checks, or checks for any other reason, are not considered extra checks. The last check received in the month is considered the extra check. Child Care Costs Allow reasonable child care costs necessary for employment or training to be deducted from income. Payroll Deductions and Union Dues Gross earnings for employed individuals who are not aged, blind, or disabled applicants or recipients are reduced by mandatory payroll deductions and union dues actually withheld or actually paid or $90 whichever is greater. Child Support The First $50 per month of current child support, received on behalf of children in the Medicaid unit, will be disregarded from each budget unit that is budgeted with a separate income level. Adult Dependent Care Expenses Reasonable adult dependent care expenses incurred for any incapacitated or disabled adult in the Medicaid unit are allowed as a deduction from income so a caretaker or spouse can work or attend training. Car Safety Seat The cost to purchase or rent a car safety seat for a child through age 10 is allowed as a deduction if a seat is not otherwise reasonably available. Subsidized Guardianship Payments Disregard subsidized guardianship payments for children. Child and Adult Food Program Disregard payments from the Child and Adult Food Program for meals and snacks to licensed families who provide daycare in their home. Military Personnel Additional Pay Additional pay received by military personnel as a result of deployment to a combat zone is disregarded as income. TANF Cash Grant Disregard TANF cash grant as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Yes No

Name of resource type: Description: Salability of "Contractual Rights to Receive Payment" An applicant/recipient may rebut the presumption of the salability of "contractual rights to receive payment" by showing the following. a. That his interest in the contract was advertised for sale in a newspaper whose circulation area includes the area where the real property relating to the contract is located. This advertisement must be published successively for two weeks if the newspaper is a weekly and for one week if it is a daily. b.The sworn statement of the applicant/ recipient that no oſers were received which equaled or exceeded the minimum price. If all oſers were below the minimum price, the property is determined to be not saleable; any oſer received that is equal to or in excess of the minimum price will establish that the property is saleable and the seller has the right to accept any of the oſers. Rebuttals must be made immediately prior to each redetermination of eligibility for the property to continue to be treated as unsalable. Eſective Date of Eligibility Eſective Date of Eligibility - An individual is considered resource eligible for the full month if he/she attains resource eligibility on any day of the month, without regard to whether the individual was resource eligible on the ţrst moment of the ţrst day of the month. Life Estate Eſective July 1, 1996 the value of a life estate will be excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Value of Mineral Acres The value of mineral acres are excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Employee Beneţt Annuity The value of an employee beneţt annuity that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simpliţed employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in § 408 of the Internal Revenue Code of 1986 is excluded. A speciţed type of resource is disregarded:

Name of resource type: Description: State Tax Refunds State tax refunds and refundable tax credits are excluded as resources for nine months beginning after the month of receipt. Real or Personal Property Real or personal property which is not saleable without working an undue hardship may be considered unavailable in determining Medical Assistance eligibility. Property which has been, in good faith, oſered for sale, and for which no oſer has been received which equals or exceeds 75% of the reasonable market value, will normally be treated as not saleable without working an undue hardship. A good faith oſer to sell real property would normally include advertisements and listings with real estate agents or local dealers in real estate. The reasonable market value of real property may be established by appraisal or by any other method which is likely to produce an accurate valuation. Valuations established for real estate tax purposes shall not be used. A good faith oſer to sell personal property would normally include advertisements, listing with real estate agents or local dealers. The reasonable market value of personal property may be established by appraisals or by any other method which is likely to produce an accurate valuation. A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Speciţed Low Income Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Income Standard Used Family income must be above 100% FPL and below 120% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-beneţt low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment for Medicare Part B premiums.

Speciţed Low Income Medicare Beneţciaries MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Individuals with income at or above 120% and below 135% of the FPL who are entitled to Medicare Part A, who qualify for payment of Medicare Part B premiums. Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 The state covers the mandatory qualifying individuals group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet all of the following criteria: 1. Would qualify as Qualiţed Medicare Beneţciaries (described in section 1905(p)(1) of the Act), except that their income exceeds the income level for that eligibility group.

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

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

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Financial Methodologies 1. SSI methodologies are used in calculating household income. Please refer as necessary to Non-MAGI Methodologies, completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: Guardian or Conservator The legally appointed guardian or conservator may be allowed to retain 5 percent of a recipient's monthly beneţts as reimbursement for services. The remainder of the recipient's monthly beneţt shall be considered available to the Medical Assistance Unit. Amount: $25.00 Description of disregard: The ţrst $25 of unearned income from rental of rooms, apartments, or other property from each unit is exempt to defray any associated expenses. Description of disregard: All wages paid by the Census Bureau for temporary employment related to census activities are excluded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: For each individual who is not an aged, blind, or disabled recipient within a family who is employed or in training, deduct the $30 standard work/ training expense allowance. Yes No General income disregard: A speciţed amount of unearned income is disregarded. Census Bureau wages are disregarded. Interest is disregarded. Dividends are disregarded. Training allowances and expenses are disregarded. A speciţed type of income is disregarded:

Name of income type: Description: Name of income type: Description: Military Personnel Additional Pay Additional pay received by military personnel as a result of deployment to a combat zone is disregarded as income. TANF Cash Grant Disregard TANF cash grant as income. Car Safety Seat The cost to purchase or rent a car safety seat for a child through age 10 is allowed as a deduction if a seat is not otherwise reasonably available. Adult Dependent Care Expenses Reasonable adult dependent care expenses incurred for any incapacitated or disabled adult in the Medicaid unit are allowed as a deduction from income so a caretaker or spouse can work or attend training. Subsidized Guardianship Payments Disregard subsidized guardianship payments for children. Child and Adult Food Program Disregard payments from the Child and Adult Food Program for meals and snacks to licensed families who provide daycare in their home. Income In-Kind Income in- kind is to be excluded except that income in-kind which is in lieu of wages is considered earned income. Extra Checks of Earned or Unearned Income Extra checks of earned or unearned income received from a regularly recurring income source are disregarded as income. Bonus checks, or checks for any other reason, are not considered extra checks. The last check received in the month is considered the extra check. Child Care Costs Allow reasonable child care costs necessary for employment or training to be deducted from income. Payroll Deductions and Union Dues Gross earnings for employed individuals who are not aged, blind, or disabled applicants or recipients are reduced by mandatory payroll deductions and union dues actually withheld or actually paid or $90 whichever is greater. Child Support The First $50 per month of current child support, received on behalf of children in the Medicaid unit, will be disregarded from each budget unit that is budgeted with a separate income level. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Yes No

Name of resource type: Description: Salability of "Contractual Rights to Receive Payment" An applicant/recipient may rebut the presumption of the salability of "contractual rights to receive payment" by showing the following. a. That his interest in the contract was advertised for sale in a newspaper whose circulation area includes the area where the real property relating to the contract is located. This advertisement must be published successively for two weeks if the newspaper is a weekly and for one week if it is a daily. b.The sworn statement of the applicant/ recipient that no oſers were received which equaled or exceeded the minimum price. If all oſers were below the minimum price, the property is determined to be not saleable; any oſer received that is equal to or in excess of the minimum price will establish that the property is saleable and the seller has the right to accept any of the oſers. Rebuttals must be made immediately prior to each redetermination of eligibility for the property to continue to be treated as unsalable. Eſective Date of Eligibility Eſective Date of Eligibility - An individual is considered resource eligible for the full month if he/she attains resource eligibility on any day of the month, without regard to whether the individual was resource eligible on the ţrst moment of the ţrst day of the month. Life Estate Eſective July 1, 1996 the value of a life estate will be excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Value of Mineral Acres The value of mineral acres are excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Employee Beneţt Annuity The value of an employee beneţt annuity that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simpliţed employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in § 408 of the Internal Revenue Code of 1986 is excluded. A speciţed type of resource is disregarded:

Name of resource type: Description: State Tax Refunds State tax refunds and refundable tax credits are excluded as resources for nine months beginning after the month of receipt. Real or Personal Property Real or personal property which is not saleable without working an undue hardship may be considered unavailable in determining Medical Assistance eligibility. Property which has been, in good faith, oſered for sale, and for which no oſer has been received which equals or exceeds 75% of the reasonable market value, will normally be treated as not saleable without working an undue hardship. A good faith oſer to sell real property would normally include advertisements and listings with real estate agents or local dealers in real estate. The reasonable market value of real property may be established by appraisal or by any other method which is likely to produce an accurate valuation. Valuations established for real estate tax purposes shall not be used. A good faith oſer to sell personal property would normally include advertisements, listing with real estate agents or local dealers. The reasonable market value of personal property may be established by appraisals or by any other method which is likely to produce an accurate valuation. A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Income Standard Used Family income must be at or above 120% FPL and below 135% FPL. D. Resource Standard Used The resource standard is the same used to determine eligibility for the Medicare Part D full-beneţt low-income subsidy (LIS) (but without regard to the life insurance policy exclusion applied in LIS resource eligibility determinations). This standard is three times the SSI resource standard, adjusted annually in accordance with the consumer price index. E. Medical Assistance Provided Medical assistance is limited to payment for Medicare Part B premiums.

Qualifying Individuals MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 F. Additional Information (optional)

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 A. Options for Coverage The state provides Medicaid to speciţed optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper-based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classiţcations of Individuals under Age 21 NEW Children with Non-IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents NEW Optional Targeted Low Income Children APPROVED Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Yes No

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

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Medically Needy Options for Coverage The state provides Medicaid to speciţed groups of individuals who are medically needy. The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Pregnant Women APPROVED Medically Needy Children under Age 18 APPROVED Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Protected Medically Needy Individuals Who Were Eligible in 1973 NEW 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Reasonable Classiţcations of Individuals under Age 21 APPROVED Medically Needy Parents and Other Caretaker Relatives APPROVED Yes No

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

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-19-0014 System-Derived SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Individuals between ages 16 and 64 with a disability, who have earned income. Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 The state covers the optional Ticket to Work basic eligibility group in accordance with the following provisions:

Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are at least age 16 but less than 65 years of age. 2. Have earned income. 3. But for earned income, meet the SSI deţnition of disability. 4. Have income and resources that do not exceed the standards established by the state.

Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Financial Methodologies 1. SSI methodologies are used in calculating household income and resources. More restrictive requirements than SSI are used in calculating countable income and/or resources. Please refer as necessary to More Restrictive Requirements than SSI under 1902(f), completed by the state. 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: Name of disregard: Description: Guardian or Conservator The legally appointed guardian or conservator may be allowed to retain 5 percent of a recipient's monthly beneţts as reimbursement for services. The remainder of the recipient's monthly beneţt shall be considered available to the Medical Assistance Unit. Amount: $25.00 Description of disregard: The ţrst $25 of unearned income from rental of rooms, apartments, or other property from each unit is exempt to defray any associated expenses. Description of disregard: All wages paid by the Census Bureau for temporary employment related to census activities are excluded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: For each individual who is not an aged, blind, or disabled recipient within a family who is employed or in training, deduct the $30 standard work/ training expense allowance. Yes No Yes No General income disregard: A speciţed amount of unearned income is disregarded. Census Bureau wages are disregarded. Interest is disregarded. Dividends are disregarded. Training allowances and expenses are disregarded.

Name of income type: Description: Income In-Kind Income in- kind is to be excluded except that income in-kind which is in lieu of wages is considered earned income. Extra Checks of Earned or Unearned Income Extra checks of earned or unearned income received from a regularly recurring income source are disregarded as income. Bonus checks, or checks for any other reason, are not considered extra checks. The last check received in the month is considered the extra check. Child Care Costs Allow reasonable child care costs necessary for employment or training to be deducted from income. Payroll Deductions and Union Dues Gross earnings for employed individuals who are not aged, blind, or disabled applicants or recipients are reduced by mandatory payroll deductions and union dues actually withheld or actually paid or $90 whichever is greater. Adult Dependent Care Expenses Reasonable adult dependent care expenses incurred for any incapacitated or disabled adult in the Medicaid unit are allowed as a deduction from income so a caretaker or spouse can work or attend training. Car Safety Seat The cost to purchase or rent a car safety seat for a child through age 10 is allowed as a deduction if a seat is not otherwise reasonably available. Subsidized Guardianship Payments Disregard subsidized guardianship payments for children. Child and Adult Food Program Disregard payments from the Child and Adult Food Program for meals and snacks to licensed families who provide daycare in their home. Military Personnel Additional Pay Additional pay received by military personnel as a result of deployment to a combat zone is disregarded as income. TANF Cash Grant Disregard TANF cash grant as income. Child Support The First $50 per month of current child support, received on behalf of children in the Medicaid unit, will be disregarded from each budget unit that is budgeted with a separate income level. 3. Less restrictive methodologies are used in calculating countable resources. A speciţed type of income is disregarded: Yes

The less restrictive resource methodologies are: Name of resource type: Description: Real or Personal Property Real or personal property which is not saleable without working an undue hardship may be considered unavailable in determining Medical Assistance eligibility. Property which has been, in good faith, oſered for sale, and for which no oſer has been received which equals or exceeds 75% of the reasonable market value, will normally be treated as not saleable without working an undue hardship. A good faith oſer to sell real property would normally include advertisements and listings with real estate agents or local dealers in real estate. The reasonable market value of real property may be established by appraisal or by any other method which is likely to produce an accurate valuation. Valuations established for real estate tax purposes shall not be used. A good faith oſer to sell personal property would normally include advertisements, listing with real estate agents or local dealers. The reasonable market value of personal property may be established by appraisals or by any other method which is likely to produce an accurate valuation. Additional Assets An additional $10,000 in assets is disregarded for each individual eligible under Ticket to Work Basic. Eſective Date of Eligibility Eſective Date of Eligibility - An individual is considered resource eligible for the full month if he/she attains resource eligibility on any day of the month, without regard to whether the individual was resource eligible on the ţrst moment of the ţrst day of the month. Life Estate Eſective July 1, 1996 the value of a life estate will be excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Value of Mineral Acres The value of mineral acres are excluded in determining if the available assets of an applicant or recipient exceed the asset limit. No A speciţed type of resource is disregarded:

Name of resource type: Description: Salability of "Contractual Rights to Receive Payment" An applicant/recipient may rebut the presumption of the salability of "contractual rights to receive payment" by showing the following. a. That his interest in the contract was advertised for sale in a newspaper whose circulation area includes the area where the real property relating to the contract is located. This advertisement must be published successively for two weeks if the newspaper is a weekly and for one week if it is a daily. b. The sworn statement of the applicant/ recipient that no oſers were received which equaled or exceeded the minimum price. If all oſers were below the minimum price, the property is determined to be not saleable; any oſer received that is equal to or in excess of the minimum price will establish that the property is saleable and the seller has the right to accept any of the oſers. Rebuttals must be made immediately prior to each redetermination of eligibility for the property to continue to be treated as unsalable. Employee Beneţt Annuity The value of an employee beneţt annuity that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simpliţed employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in § 408 of the Internal Revenue Code of 1986 is excluded. State Tax Refunds State tax refunds and refundable tax credits are excluded as resources for nine months beginning after the month of receipt. A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Income Standard Used The income standard for this group is: FPL 225.00% 1. No income standard 2. A percentage of the federal poverty level: 3. A percentage of the SSI Federal Beneţt Rate: 4. A dollar amount 5. Other

Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 D. Resource Standard Used The resource standard for this group is: Single Individual $3000.00 Couple $6000.00 1. No resource standard 2. SSI resource standard 3. The state's more restrictive resource standard described in the More Restrictive Requirements than SSI under 1902(f) - (209(b) States) RU. 4. A dollar amount higher than the SSI resource standard

Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 E. Premiums and Cost Sharing Requirements for premiums and cost sharing for this group are found in the premium and cost sharing sections of the state plan.

Ticket to Work Basic MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 F. Additional Information (optional) The resource standard amount increases by $25 for each additional person in the household. Requirements for premiums and cost sharing are found in the premium and cost sharing sections as well as page 12o of Attachment 2.6-A of the eligibility section of the state plan.

Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Woman who are pregnant or post-partum who would qualify under the state's Pregnant Women eligibility group, except for income. Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 The state covers the Medically Needy Pregnant Women eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are pregnant or post-partum, as deţned in 42 CFR 435.4. 2. Would qualify under the Pregnant Women eligibility group, except for income. 3. Are not otherwise eligible for categorically needy coverage under the state plan. 4. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Financial Methodologies 1. The ţnancial methodology used is: 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: FPL 90.00% Name of disregard: Description: Guardian or Conservator The legally appointed guardian or conservator may be allowed to retain 5 percent of a recipient' s monthly beneţts as reimbursement for services. The remainder of the recipient's monthly beneţt shall be considered available to the Medical Assistance Unit. 5% Disregard A disregard of ţve percent of the Modiţed Adjusted Gross Income is applied ţrst when determining income for the medically needy category. Amount: $25.00 Description of disregard: The ţrst $25 of unearned income from rental of rooms, apartments, or other property from each unit is exempt to defray any associated expenses. a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No The diſerence between one income standard and another is disregarded. Between the following percentages of the FPL: Between the medically needy income limit and a percentage of the FPL: Between the SSI Federal Beneţt Rate and: Between other income standards: General income disregard: A speciţed amount of unearned income is disregarded.

Description of disregard: All wages paid by the Census Bureau for temporary employment related to census activities are excluded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: For each individual who is not an aged, blind, or disabled recipient within a family who is employed or in training, deduct the $30 standard work/ training expense allowance. Name of income type: Description: Income In-Kind Income in- kind is to be excluded except that income in-kind which is in lieu of wages is considered earned income. Extra Checks of Earned or Unearned Income Extra checks of earned or unearned income received from a regularly recurring income source are disregarded as income. Bonus checks, or checks for any other reason, are not considered extra checks. The last check received in the month is considered the extra check. Child Care Costs Allow reasonable child care costs necessary for employment or training to be deducted from income. Payroll Deductions and Union Dues Gross earnings for employed individuals who are not aged, blind, or disabled applicants or recipients are reduced by mandatory payroll deductions and union dues actually withheld or actually paid or $ 90 whichever is greater. TANF Cash Grant Disregard TANF cash grant as income. Child Support The First $50 per month of current child support, received on behalf of children in the Medicaid unit, will be disregarded from each budget unit that is budgeted with a separate income level. Adult Dependent Care Expenses Reasonable adult dependent care expenses incurred for any incapacitated or disabled adult in the Medicaid unit are allowed as a deduction from income so a caretaker or spouse can work or attend training. Car Safety Seat The cost to purchase or rent a car safety seat for a child through age 10 is allowed as a deduction if a seat is not otherwise reasonably available. Census Bureau wages are disregarded. Interest is disregarded. Dividends are disregarded. Training allowances and expenses are disregarded. A speciţed type of income is disregarded:

Name of income type: Description: Subsidized Guardianship Payments Disregard subsidized guardianship payments for children. Child and Adult Food Program Disregard payments from the Child and Adult Food Program for meals and snacks to licensed families who provide daycare in their home. Military Personnel Additional Pay Additional pay received by military personnel as a result of deployment to a combat zone is disregarded as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of resource type: Description: Salability of "Contractual Rights to Receive Payment" An applicant/recipient may rebut the presumption of the salability of "contractual rights to receive payment" by showing the following. a. That his interest in the contract was advertised for sale in a newspaper whose circulation area includes the area where the real property relating to the contract is located. This advertisement must be published successively for two weeks if the newspaper is a weekly and for one week if it is a daily. b.The sworn statement of the applicant/ recipient that no oſers were received which equaled or exceeded the minimum price. If all oſers were below the minimum price, the property is determined to be not saleable; any oſer received that is equal to or in excess of the minimum price will establish that the property is saleable and the seller has the right to accept any of the oſers. Rebuttals must be made immediately prior to each redetermination of eligibility for the property to continue to be treated as unsalable. Eſective Date of Eligibility Eſective Date of Eligibility - An individual is considered resource eligible for the full month if he/she attains resource eligibility on any day of the month, without regard to whether the individual was resource eligible on the ţrst moment of the ţrst day of the month. Yes No A speciţed type of resource is disregarded:

Name of resource type: Description: Life Estate Eſective July 1, 1996 the value of a life estate will be excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Employee Beneţt Annuity The value of an employee beneţt annuity that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simpliţed employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in § 408 of the Internal Revenue Code of 1986 is excluded. State Tax Refunds State tax refunds and refundable tax credits are excluded as resources for nine months beginning after the month of receipt. Real or Personal Property Real or personal property which is not saleable without working an undue hardship may be considered unavailable in determining Medical Assistance eligibility. Property which has been, in good faith, oſered for sale, and for which no oſer has been received which equals or exceeds 75% of the reasonable market value, will normally be treated as not saleable without working an undue hardship. A good faith oſer to sell real property would normally include advertisements and listings with real estate agents or local dealers in real estate. The reasonable market value of real property may be established by appraisal or by any other method which is likely to produce an accurate valuation. Valuations established for real estate tax purposes shall not be used. A good faith oſer to sell personal property would normally include advertisements, listing with real estate agents or local dealers. The reasonable market value of personal property may be established by appraisals or by any other method which is likely to produce an accurate valuation. Value of Mineral Acres The value of mineral acres are excluded in determining if the available assets of an applicant or recipient exceed the asset limit. A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. D. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU. E. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is deţned in the Handling of Excess Income (Spenddown) RU.

Medically Needy Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 F. Additional Information (optional) Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Children under age 18 who would qualify under the state's categorically needy eligibility groups, except for income. Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 The state covers the Medically Needy Children under Age 18 eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 18. 2. Would qualify as categorically needy, except for income. 3. Are not otherwise eligible for categorically needy coverage under the state plan. 4. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Financial Methodologies 1. The ţnancial methodology used is: 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: FPL 92.00% Name of disregard: Description: Guardian or Conservator The legally appointed guardian or conservator may be allowed to retain 5 percent of a recipient' s monthly beneţts as reimbursement for services. The remainder of the recipient's monthly beneţt shall be considered available to the Medical Assistance Unit. 5% Disregard A disregard of ţve percent of the Modiţed Adjusted Gross Income is applied ţrst when determining income for the medically needy category. Amount: $25.00 Description of disregard: The ţrst $25 of unearned income from rental of rooms, apartments, or other property from each unit is exempt to defray any associated expenses. Description of disregard: All wages paid by the Census Bureau for temporary employment a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No The diſerence between one income standard and another is disregarded. Between the following percentages of the FPL: Between the medically needy income limit and a percentage of the FPL: Between the SSI Federal Beneţt Rate and: Between other income standards: General income disregard: A speciţed amount of unearned income is disregarded.

related to census activities are excluded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: For each individual who is not an aged, blind, or disabled recipient within a family who is employed or in training, deduct the $30 standard work/ training expense allowance. Name of income type: Description: Income In-Kind Income in- kind is to be excluded except that income in-kind which is in lieu of wages is considered earned income. Extra Checks of Earned or Unearned Income Extra checks of earned or unearned income received from a regularly recurring income source are disregarded as income. Bonus checks, or checks for any other reason, are not considered extra checks. The last check received in the month is considered the extra check. Child Care Costs Allow reasonable child care costs necessary for employment or training to be deducted from income. Payroll Deductions and Union Dues Gross earnings for employed individuals who are not aged, blind, or disabled applicants or recipients are reduced by mandatory payroll deductions and union dues actually withheld or actually paid or $ 90 whichever is greater. TANF Cash Grant Disregard TANF cash grant as income. Child Support The First $50 per month of current child support, received on behalf of children in the Medicaid unit, will be disregarded from each budget unit that is budgeted with a separate income level. Adult Dependent Care Expenses Reasonable adult dependent care expenses incurred for any incapacitated or disabled adult in the Medicaid unit are allowed as a deduction from income so a caretaker or spouse can work or attend training. Car Safety Seat The cost to purchase or rent a car safety seat for a child through age 10 is allowed as a deduction if a seat is not otherwise reasonably available. Subsidized Guardianship Payments Disregard subsidized guardianship payments for children. Census Bureau wages are disregarded. Interest is disregarded. Dividends are disregarded. Training allowances and expenses are disregarded. A speciţed type of income is disregarded:

Name of income type: Description: Child and Adult Food Program Disregard payments from the Child and Adult Food Program for meals and snacks to licensed families who provide daycare in their home. Military Personnel Additional Pay Additional pay received by military personnel as a result of deployment to a combat zone is disregarded as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of resource type: Description: Salability of "Contractual Rights to Receive Payment" An applicant/recipient may rebut the presumption of the salability of "contractual rights to receive payment" by showing the following. a. That his interest in the contract was advertised for sale in a newspaper whose circulation area includes the area where the real property relating to the contract is located. This advertisement must be published successively for two weeks if the newspaper is a weekly and for one week if it is a daily. b.The sworn statement of the applicant/ recipient that no oſers were received which equaled or exceeded the minimum price. If all oſers were below the minimum price, the property is determined to be not saleable; any oſer received that is equal to or in excess of the minimum price will establish that the property is saleable and the seller has the right to accept any of the oſers. Rebuttals must be made immediately prior to each redetermination of eligibility for the property to continue to be treated as unsalable. Eſective Date of Eligibility Eſective Date of Eligibility - An individual is considered resource eligible for the full month if he/she attains resource eligibility on any day of the month, without regard to whether the individual was resource eligible on the ţrst moment of the ţrst day of the month. Yes No A speciţed type of resource is disregarded:

Name of resource type: Description: Life Estate Eſective July 1, 1996 the value of a life estate will be excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Employee Beneţt Annuity The value of an employee beneţt annuity that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simpliţed employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in § 408 of the Internal Revenue Code of 1986 is excluded. State Tax Refunds State tax refunds and refundable tax credits are excluded as resources for nine months beginning after the month of receipt. Real or Personal Property Real or personal property which is not saleable without working an undue hardship may be considered unavailable in determining Medical Assistance eligibility. Property which has been, in good faith, oſered for sale, and for which no oſer has been received which equals or exceeds 75% of the reasonable market value, will normally be treated as not saleable without working an undue hardship. A good faith oſer to sell real property would normally include advertisements and listings with real estate agents or local dealers in real estate. The reasonable market value of real property may be established by appraisal or by any other method which is likely to produce an accurate valuation. Valuations established for real estate tax purposes shall not be used. A good faith oſer to sell personal property would normally include advertisements, listing with real estate agents or local dealers. The reasonable market value of personal property may be established by appraisals or by any other method which is likely to produce an accurate valuation. Value of Mineral Acres The value of mineral acres are excluded in determining if the available assets of an applicant or recipient exceed the asset limit. A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. D. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU. E. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is deţned in the Handling of Excess Income (Spenddown) RU.

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 F. Additional Information (optional)

Medically Needy Children under Age 18 MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Reasonable Classiţcations of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 One or more reasonable classiţcations of individuals under age 21 who do not qualify as categorically needy. Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 The state covers the optional Medically Needy Reasonable Classiţcations of Individuals under Age 21 eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria:

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

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

Medically Needy Reasonable Classiţcations of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Individuals Covered The state covers the following populations: 1. All children under a speciţed age limit: i. Under age 21 ii. Under age 20 iii. Under age 19 2. Reasonable classiţcations of children

Medically Needy Reasonable Classiţcations of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Financial Methodologies 1. The state uses the same ţnancial methodology for all individuals covered. 2. The ţnancial methodology used is: 3. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: FPL 92.00% Name of disregard: Description: Guardian or Conservator The legally appointed guardian or conservator may be allowed to retain 5 percent of a recipient' s monthly beneţts as reimbursement for services. The remainder of the recipient's monthly beneţt shall be considered available to the Medical Assistance Unit. 5% Disregard A disregard of ţve percent of the Modiţed Adjusted Gross Income is applied ţrst when determining income for the medically needy category. Amount: $25.00 Yes No a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No The diſerence between one income standard and another is disregarded. Between the following percentages of the FPL: Between the medically needy income limit and a percentage of the FPL: Between the SSI Federal Beneţt Rate and: Between other income standards: General income disregard: A speciţed amount of unearned income is disregarded.

Description of disregard: The ţrst $25 of unearned income from rental of rooms, apartments, or other property from each unit is exempt to defray any associated expenses. Description of disregard: All wages paid by the Census Bureau for temporary employment related to census activities are excluded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: For each individual who is not an aged, blind, or disabled recipient within a family who is employed or in training, deduct the $30 standard work/ training expense allowance. Name of income type: Description: Income In-Kind Income in- kind is to be excluded except that income in-kind which is in lieu of wages is considered earned income. Extra Checks of Earned or Unearned Income Extra checks of earned or unearned income received from a regularly recurring income source are disregarded as income. Bonus checks, or checks for any other reason, are not considered extra checks. The last check received in the month is considered the extra check. Child Care Costs Allow reasonable child care costs necessary for employment or training to be deducted from income. Payroll Deductions and Union Dues Gross earnings for employed individuals who are not aged, blind, or disabled applicants or recipients are reduced by mandatory payroll deductions and union dues actually withheld or actually paid or $ 90 whichever is greater. TANF Cash Grant Disregard TANF cash grant as income. Child Support The First $50 per month of current child support, received on behalf of children in the Medicaid unit, will be disregarded from each budget unit that is budgeted with a separate income level. Adult Dependent Care Expenses Reasonable adult dependent care expenses incurred for any incapacitated or disabled adult in the Medicaid unit are allowed as a deduction from income so a caretaker or spouse can work or attend training. Census Bureau wages are disregarded. Interest is disregarded. Dividends are disregarded. Training allowances and expenses are disregarded. A speciţed type of income is disregarded:

Name of income type: Description: Car Safety Seat The cost to purchase or rent a car safety seat for a child through age 10 is allowed as a deduction if a seat is not otherwise reasonably available. Subsidized Guardianship Payments Disregard subsidized guardianship payments for children. Child and Adult Food Program Disregard payments from the Child and Adult Food Program for meals and snacks to licensed families who provide daycare in their home. Military Personnel Additional Pay Additional pay received by military personnel as a result of deployment to a combat zone is disregarded as income. 4. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of resource type: Description: Salability of "Contractual Rights to Receive Payment" An applicant/recipient may rebut the presumption of the salability of "contractual rights to receive payment" by showing the following. a. That his interest in the contract was advertised for sale in a newspaper whose circulation area includes the area where the real property relating to the contract is located. This advertisement must be published successively for two weeks if the newspaper is a weekly and for one week if it is a daily. b.The sworn statement of the applicant/ recipient that no oſers were received which equaled or exceeded the minimum price. If all oſers were below the minimum price, the property is determined to be not saleable; any oſer received that is equal to or in excess of the minimum price will establish that the property is saleable and the seller has the right to accept any of the oſers. Rebuttals must be made immediately prior to each redetermination of eligibility for the property to continue to be treated as unsalable. Yes No A speciţed type of resource is disregarded:

Name of resource type: Description: Eſective Date of Eligibility Eſective Date of Eligibility - An individual is considered resource eligible for the full month if he/she attains resource eligibility on any day of the month, without regard to whether the individual was resource eligible on the ţrst moment of the ţrst day of the month. Life Estate Eſective July 1, 1996 the value of a life estate will be excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Employee Beneţt Annuity The value of an employee beneţt annuity that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simpliţed employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in § 408 of the Internal Revenue Code of 1986 is excluded. State Tax Refunds State tax refunds and refundable tax credits are excluded as resources for nine months beginning after the month of receipt. Real or Personal Property Real or personal property which is not saleable without working an undue hardship may be considered unavailable in determining Medical Assistance eligibility. Property which has been, in good faith, oſered for sale, and for which no oſer has been received which equals or exceeds 75% of the reasonable market value, will normally be treated as not saleable without working an undue hardship. A good faith oſer to sell real property would normally include advertisements and listings with real estate agents or local dealers in real estate. The reasonable market value of real property may be established by appraisal or by any other method which is likely to produce an accurate valuation. Valuations established for real estate tax purposes shall not be used. A good faith oſer to sell personal property would normally include advertisements, listing with real estate agents or local dealers. The reasonable market value of personal property may be established by appraisals or by any other method which is likely to produce an accurate valuation. Value of Mineral Acres The value of mineral acres are excluded in determining if the available assets of an applicant or recipient exceed the asset limit.

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

Medically Needy Reasonable Classiţcations of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 D. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. E. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU. F. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is deţned in the Handling of Excess Income (Spenddown) RU.

Medically Needy Reasonable Classiţcations of Individuals under Age 21 MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 G. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Parents and Other Caretaker Relatives MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Parents and other caretaker relatives of dependent children who do not qualify as categorically needy. Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 The state covers the optional Medically Needy Parents and Other Caretaker Relatives eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Meet the deţnition of parent or caretaker relative, as described in the mandatory Parents and Other Caretaker Relatives eligibility group. 2. Are not otherwise eligible for categorically needy coverage under the state plan. 3. Have income at or below the medically needy income level and resources at or below the medically needy resource level.

Medically Needy Parents and Other Caretaker Relatives MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Financial Methodologies 1. The ţnancial methodology used is: 2. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: FPL 93.00% Name of disregard: Description: Guardian or Conservator The legally appointed guardian or conservator may be allowed to retain 5 percent of a recipient' s monthly beneţts as reimbursement for services. The remainder of the recipient's monthly beneţt shall be considered available to the Medical Assistance Unit. 5% Disregard A disregard of ţve percent of the Modiţed Adjusted Gross Income is applied ţrst when determining income for the medically needy category. Amount: $25.00 Description of disregard: The ţrst $25 of unearned income from rental of rooms, apartments, or other property from each unit is exempt to defray any associated expenses. Description of disregard: All wages paid by the Census Bureau for temporary employment a. AFDC methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b. MAGI-like methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. Yes No The diſerence between one income standard and another is disregarded. Between the following percentages of the FPL: Between the medically needy income limit and a percentage of the FPL: Between the SSI Federal Beneţt Rate and: Between other income standards: General income disregard: A speciţed amount of unearned income is disregarded. Census Bureau wages are disregarded.

related to census activities are excluded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: For each individual who is not an aged, blind, or disabled recipient within a family who is employed or in training, deduct the $30 standard work/ training expense allowance. Name of income type: Description: Income In-Kind Income in- kind is to be excluded except that income in-kind which is in lieu of wages is considered earned income. Extra Checks of Earned or Unearned Income Extra checks of earned or unearned income received from a regularly recurring income source are disregarded as income. Bonus checks, or checks for any other reason, are not considered extra checks. The last check received in the month is considered the extra check. Child Care Costs Allow reasonable child care costs necessary for employment or training to be deducted from income. Payroll Deductions and Union Dues Gross earnings for employed individuals who are not aged, blind, or disabled applicants or recipients are reduced by mandatory payroll deductions and union dues actually withheld or actually paid or $ 90 whichever is greater. TANF Cash Grant Disregard TANF cash grant as income. Child Support The First $50 per month of current child support, received on behalf of children in the Medicaid unit, will be disregarded from each budget unit that is budgeted with a separate income level. Adult Dependent Care Expenses Reasonable adult dependent care expenses incurred for any incapacitated or disabled adult in the Medicaid unit are allowed as a deduction from income so a caretaker or spouse can work or attend training. Car Safety Seat The cost to purchase or rent a car safety seat for a child through age 10 is allowed as a deduction if a seat is not otherwise reasonably available. Subsidized Guardianship Payments Disregard subsidized guardianship payments for children. Interest is disregarded. Dividends are disregarded. Training allowances and expenses are disregarded. A speciţed type of income is disregarded:

Name of income type: Description: Child and Adult Food Program Disregard payments from the Child and Adult Food Program for meals and snacks to licensed families who provide daycare in their home. Military Personnel Additional Pay Additional pay received by military personnel as a result of deployment to a combat zone is disregarded as income. 3. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of resource type: Description: Salability of "Contractual Rights to Receive Payment" An applicant/recipient may rebut the presumption of the salability of "contractual rights to receive payment" by showing the following. a. That his interest in the contract was advertised for sale in a newspaper whose circulation area includes the area where the real property relating to the contract is located. This advertisement must be published successively for two weeks if the newspaper is a weekly and for one week if it is a daily. b.The sworn statement of the applicant/ recipient that no oſers were received which equaled or exceeded the minimum price. If all oſers were below the minimum price, the property is determined to be not saleable; any oſer received that is equal to or in excess of the minimum price will establish that the property is saleable and the seller has the right to accept any of the oſers. Rebuttals must be made immediately prior to each redetermination of eligibility for the property to continue to be treated as unsalable. Eſective Date of Eligibility Eſective Date of Eligibility - An individual is considered resource eligible for the full month if he/she attains resource eligibility on any day of the month, without regard to whether the individual was resource eligible on the ţrst moment of the ţrst day of the month. Yes No A speciţed type of resource is disregarded:

Name of resource type: Description: Life Estate Eſective July 1, 1996 the value of a life estate will be excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Employee Beneţt Annuity The value of an employee beneţt annuity that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simpliţed employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in § 408 of the Internal Revenue Code of 1986 is excluded. State Tax Refunds State tax refunds and refundable tax credits are excluded as resources for nine months beginning after the month of receipt. Real or Personal Property Real or personal property which is not saleable without working an undue hardship may be considered unavailable in determining Medical Assistance eligibility. Property which has been, in good faith, oſered for sale, and for which no oſer has been received which equals or exceeds 75% of the reasonable market value, will normally be treated as not saleable without working an undue hardship. A good faith oſer to sell real property would normally include advertisements and listings with real estate agents or local dealers in real estate. The reasonable market value of real property may be established by appraisal or by any other method which is likely to produce an accurate valuation. Valuations established for real estate tax purposes shall not be used. A good faith oſer to sell personal property would normally include advertisements, listing with real estate agents or local dealers. The reasonable market value of personal property may be established by appraisals or by any other method which is likely to produce an accurate valuation. Value of Mineral Acres The value of mineral acres are excluded in determining if the available assets of an applicant or recipient exceed the asset limit. A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Medically Needy Parents and Other Caretaker Relatives MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU. D. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU. E. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is deţned in the Handling of Excess Income (Spenddown) RU.

Medically Needy Parents and Other Caretaker Relatives MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 F. Additional Information (optional)

Medicaid State Plan Eligibility Eligibility Groups - Medically Needy Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Individuals who are age 65 or older or who have blindness or a disability who do not qualify as categorically needy. Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 The state covers the optional Medically Needy Populations Based on Age, Blindness or Disability eligibility group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1.Meet at least one of the following: a. Are age 65 or older;

b. Have blindness; or

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

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 B. Individuals Covered The state covers the following populations: 1. Individuals age 65 or older 2. Individuals with blindness 3. Individuals who have a disability

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 C. Financial Methodologies 1. The state uses the same ţnancial methodology for all individuals covered. 2. The ţnancial methodology used is: c. Less restrictive methodologies are used in calculating countable income. The less restrictive income methodologies are: FPL 83.00% Name of disregard: Description: Guardian or Conservator The legally appointed guardian or conservator may be allowed to retain 5 percent of a recipient' s monthly beneţts as reimbursement for services. The remainder of the recipient's monthly beneţt shall be considered available to the Medical Assistance Unit. Amount: $25.00 Yes No a. SSI methodologies. Please refer as necessary to Non-MAGI Methodologies, completed by the state. b.More restrictive requirements than SSI. Please refer as necessary to More Restrictive Requirements than SSI under 1902(f), completed by the state. Yes No The diſerence between one income standard and another is disregarded. Between the following percentages of the FPL: Between the medically needy income limit and a percentage of the FPL: Between the SSI Federal Beneţt Rate and: Between other income standards: General income disregard: A speciţed amount of unearned income is disregarded.

Description of disregard: The ţrst $25 of unearned income from rental of rooms, apartments, or other property from each unit is exempt to defray any associated expenses. Description of disregard: All wages paid by the Census Bureau for temporary employment related to census activities are excluded. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: Dividend and interest income from liquid assets is disregarded as income. Description of disregard: For each individual who is not an aged, blind, or disabled recipient within a family who is employed or in training, deduct the $30 standard work/ training expense allowance. Name of income type: Description: Income In-Kind Income in- kind is to be excluded except that income in-kind which is in lieu of wages is considered earned income. Extra Checks of Earned or Unearned Income Extra checks of earned or unearned income received from a regularly recurring income source are disregarded as income. Bonus checks, or checks for any other reason, are not considered extra checks. The last check received in the month is considered the extra check. Child Care Costs Allow reasonable child care costs necessary for employment or training to be deducted from income. Payroll Deductions and Union Dues Gross earnings for employed individuals who are not aged, blind, or disabled applicants or recipients are reduced by mandatory payroll deductions and union dues actually withheld or actually paid or $ 90 whichever is greater. Census Bureau wages are disregarded. Interest is disregarded. Dividends are disregarded. Training allowances and expenses are disregarded. A speciţed type of income is disregarded:

Name of income type: Description: TANF Cash Grant Disregard TANF cash grant as income. Child Support The First $50 per month of current child support, received on behalf of children in the Medicaid unit, will be disregarded from each budget unit that is budgeted with a separate income level. Adult Dependent Care Expenses Reasonable adult dependent care expenses incurred for any incapacitated or disabled adult in the Medicaid unit are allowed as a deduction from income so a caretaker or spouse can work or attend training. Car Safety Seat The cost to purchase or rent a car safety seat for a child through age 10 is allowed as a deduction if a seat is not otherwise reasonably available. Subsidized Guardianship Payments Disregard subsidized guardianship payments for children. Child and Adult Food Program Disregard payments from the Child and Adult Food Program for meals and snacks to licensed families who provide daycare in their home. Military Personnel Additional Pay Additional pay received by military personnel as a result of deployment to a combat zone is disregarded as income. d. Less restrictive methodologies are used in calculating countable resources. The less restrictive resource methodologies are: Name of resource type: Description: Yes No A speciţed type of resource is disregarded:

Name of resource type: Description: Salability of "Contractual Rights to Receive Payment" An applicant/recipient may rebut the presumption of the salability of "contractual rights to receive payment" by showing the following. a. That his interest in the contract was advertised for sale in a newspaper whose circulation area includes the area where the real property relating to the contract is located. This advertisement must be published successively for two weeks if the newspaper is a weekly and for one week if it is a daily. b.The sworn statement of the applicant/ recipient that no oſers were received which equaled or exceeded the minimum price. If all oſers were below the minimum price, the property is determined to be not saleable; any oſer received that is equal to or in excess of the minimum price will establish that the property is saleable and the seller has the right to accept any of the oſers. Rebuttals must be made immediately prior to each redetermination of eligibility for the property to continue to be treated as unsalable. Eſective Date of Eligibility Eſective Date of Eligibility - An individual is considered resource eligible for the full month if he/she attains resource eligibility on any day of the month, without regard to whether the individual was resource eligible on the ţrst moment of the ţrst day of the month. Life Estate Eſective July 1, 1996 the value of a life estate will be excluded in determining if the available assets of an applicant or recipient exceed the asset limit. Value of Mineral Acres The value of mineral acres are excluded in determining if the available assets of an applicant or recipient exceed the asset limit.

Name of resource type: Description: Employee Beneţt Annuity The value of an employee beneţt annuity that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simpliţed employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in § 408 of the Internal Revenue Code of 1986 is excluded. State Tax Refunds State tax refunds and refundable tax credits are excluded as resources for nine months beginning after the month of receipt. Real or Personal Property Real or personal property which is not saleable without working an undue hardship may be considered unavailable in determining Medical Assistance eligibility. Property which has been, in good faith, oſered for sale, and for which no oſer has been received which equals or exceeds 75% of the reasonable market value, will normally be treated as not saleable without working an undue hardship. A good faith oſer to sell real property would normally include advertisements and listings with real estate agents or local dealers in real estate. The reasonable market value of real property may be established by appraisal or by any other method which is likely to produce an accurate valuation. Valuations established for real estate tax purposes shall not be used. A good faith oſer to sell personal property would normally include advertisements, listing with real estate agents or local dealers. The reasonable market value of personal property may be established by appraisals or by any other method which is likely to produce an accurate valuation.

Name of resource type: Description: Resource Standards Disregard countable resources, for single individuals, between $2,000 and $3,000, and, for couples (or 2-person households), between $3,000 and $6,000 (+$25 for each additional individual). A beneţciary of a "qualiţed state long-term care insurance partnership" policy (partnership policy), as deţned in section 1917(b)(1)(C) of the Social Security Act and 45 CFR 144.200 et seq., is provided a resource disregard, equal to the amount of the insurance beneţt payments made to or on behalf of the individual from the partnership policy.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 D. Income Standard Used The income standard used for this group is described in the Medically Needy Income Level RU.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 E. Resource Standard Used The resource standard used for this group is described in the Medically Needy Resource Level RU.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 F. Spenddown The state allows individuals to deduct incurred medical and remedial expenses (spend down) to become eligible under this group. Spenddown is deţned in the Handling of Excess Income (Spenddown) RU.

Medically Needy Populations Based on Age, Blindness or Disability MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0004O | ND-19-0017 Package Header Package ID ND2019MS0004O Submission Type OŰcial Approval Date 8/17/2020 Superseded SPA ID ND-10-0002 User-Entered SPA ID ND-19-0017 Initial Submission Date 9/30/2019 Eſective Date 8/1/2019 G. Additional Information (optional)

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 8/31/2020 3:02 PM EDT

_____________________________________________________________________________ Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: 19-0022 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages TN: ND-19-0022 Approval Date: 8/21/2020 Effective Date: 01/01/2020

Records / Submission Packages - View All ND - Submission Package - ND2019MS0005O - (ND-19-0022) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID ND2019MS0005O Program Name N/A SPA ID ND-19-0022 Version Number 4 Submitted By LeeAnn Thiel Package Disposition Priority Code P2 Submission Type OŰcial State ND Region Denver, CO Package Status Approved Submission Date 12/31/2019 Approval Date 8/21/2020 1:08 PM EDT Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter RAI Transaction Logs News Related Actions

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 601 E. 12th Street, Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services August 21, 2020 Christopher Jones Executive Director ND Medical Services Dept 325 600 E Boulevard Ave Bismarck, ND 58505 Re: Approval of State Plan Amendment ND-19-0022 Dear Christopher Jones: On December 31, 2019, the Centers for Medicare and Medicaid Services (CMS) received North Dakota State Plan Amendment (SPA) ND-19-0022 to move children previously enrolled in the State's stand-alone Children's Health Insurance Program (CHIP) to Medicaid as Optional Targeted Low-Income Children. We approve North Dakota State Plan Amendment (SPA) ND-19-0022 on August 21, 2020 with an eſective date(s) of January 01, 2020. Name Date Created No items available If you have any questions regarding this amendment, please contact Curtis Volesky at curtis.volesky@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services RAI CMS is issuing this Request for Additional Information (RAI) pursuant to Section 1915(f) of the Social Security Act (added by P.L. 97-35). This request has the eſect of stopping the 90-day time period for CMS to act on the material. A new 90 day time frame will not begin until we receive your response to this request.In accordance with our guidelines to all State Medicaid directors dated January 2, 2001, and subsequently reiterated in the August 16, 2018 Center for Medicaid and CHIP Services Informational Bulletin, if a response to a formal request for additional information from CMS is not received from the state within 90 days of issuance, CMS will initiate disapproval of the SPA or waiver action. In addition, because this amendment was submitted after January 2, 2001 and is eſective after January 1, 2001, please be advised that we will defer federal ţnancial participation (FFP) for state payments made in accordance with this amendment until it is approved. Upon approval, FFP will be available for the period beginning with the eſective date through the date of approval.

Submission Package ND2019MS0005O Authority Eligibility State ND Agency Name ND Medical Services Submission Date Dec 31, 2019 Priority Code P2 All Questions Question ID Reference CMS question to the State Policy/Regulation State Response 1 CHIP Proxy North Dakota has the authority to use an M-CHIP proxy methodology to calculate and claim expenditures related to M-CHIP through the CMS- approved CHIP state plan amendment (SPA), ND-13-0101. Since the approval of ND-13-0101, CMS identiţed issues in the state’s reporting of Medicaid and CHIP expenditures related to the proxy methodology in violation of federal reporting requirements at 42 CFR §433.32(a). CMS requested in correspondences dating back to 2016 that the state correct its reporting of the M-CHIP expenditures. CMS is requesting the state submit a timeline that includes submitting a CHIP SPA and demonstrating that the state is complying with federal reporting requirements. 42 CFR §433.32(a) North Dakota has submitted to CMS a CHIP SPA that includes revised language related to reporting M-CHIP Proxy expenditures. The state will continue to work with CMS to reach agreement expenditure reporting under the Proxy Methodology. Submission Package was updated by the State in accordance with the response above Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0005O | ND-19-0022 Package Header Package ID ND2019MS0005O Submission Type OŰcial Approval Date 8/21/2020 Superseded SPA ID N/A SPA ID ND-19-0022 Initial Submission Date 12/31/2019 Eſective Date N/A State Information State/Territory Name: North Dakota Medicaid Agency Name: ND Medical Services Submission Component Yes No State Plan Amendment Medicaid CHIP

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0005O | ND-19-0022 Package Header Package ID ND2019MS0005O Submission Type OŰcial Approval Date 8/21/2020 Superseded SPA ID N/A SPA ID ND-19-0022 Initial Submission Date 12/31/2019 Eſective Date N/A SPA ID and Eſective Date SPA ID ND-19-0022 Reviewable Unit Proposed Eſective Date Superseded SPA ID Optional Eligibility Groups 1/1/2020 ND-19-0017 Optional Targeted Low Income Children 1/1/2020 ND-13-0017-MM1 Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0005O | ND-19-0022 Package Header Package ID ND2019MS0005O Submission Type OŰcial Approval Date 8/21/2020 Superseded SPA ID N/A SPA ID ND-19-0022 Initial Submission Date 12/31/2019 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives Children previously enrolled in the State's stand-alone Childrens Health Insurance Program (CHIP) will now be enrolled with Medicaid as Optional Targeted Low-Income Children. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2020 $491006 Second 2021 $1926805 Federal Statute / Regulation Citation 42 CFR 435.229 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0005O | ND-19-0022 Package Header Package ID ND2019MS0005O Submission Type OŰcial Approval Date 8/21/2020 Superseded SPA ID N/A SPA ID ND-19-0022 Initial Submission Date 12/31/2019 Eſective Date N/A Governor's OŰce Review Describe Authority to prepare and submit Medicaid State Plans is provided to the Medicaid single state agency No comment Comments received No response within 45 days Other

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0005O | ND-19-0022 Package Header Package ID ND2019MS0005O Submission Type OŰcial Approval Date 8/21/2020 Superseded SPA ID N/A SPA ID ND-19-0022 Initial Submission Date 12/31/2019 Eſective Date N/A Indicate whether public comment was solicited with respect to this submission. Indicate how public comment was solicited: Name of Paper: Date of Publication: Locations covered: Bismarck Tribune 6/20/2019 entire state Grand Forks Herald 6/20/2019 entire state Fargo Forum 6/24/2019 entire state Select the type of website Date of Posting: Jun 20, 2019 Website URL: http://www.nd.gov/dhs/info/publicnotice/2019/6-20-public- notice-medicaid-changes-7-1-2019.pdf Upload copies of public notices and other documents used Name Date Created Public Notice 7-1-19 10/28/2019 12:33 PM EDT Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Newspaper Announcement Publication in state's administrative record, in accordance with the administrative procedures requirements Email to Electronic Mailing List or Similar Mechanism Website Notice Website of the State Medicaid Agency or Responsible Agency Website for State Regulations Other Public Hearing or Meeting Other method

Upload with this application a written summary of public comments received (optional) Name Date Created No items available Indicate the key issues raised during the public comment period (optional) Access Quality Cost Payment methodology Eligibility Beneţts Service delivery Other issue

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0005O | ND-19-0022 Package Header Package ID ND2019MS0005O Submission Type OŰcial Approval Date 8/21/2020 Superseded SPA ID N/A SPA ID ND-19-0022 Initial Submission Date 12/31/2019 Eſective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state This state plan amendment is likely to have a direct eſect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner: Date of solicitation/consultation: Method of solicitation/consultation: 7/1/2019 letter 8/20/2019 tribal consultation meeting States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: Date of consultation: Method of consultation: 7/1/2019 letter 8/20/2019 tribal consultation meeting The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created Yes No Yes No The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. All Indian Health Programs All Urban Indian Organizations All Indian Tribes

Name Date Created Kirstin Michel 10/28/2019 12:25 PM EDT Indicate the key issues raised (optional) Access Quality Cost Payment methodology Eligibility Beneţts Service delivery Other issue

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0005O | ND-19-0022 Package Header Package ID ND2019MS0005O Submission Type OŰcial Approval Date 8/21/2020 Superseded SPA ID ND-19-0017 User-Entered SPA ID ND-19-0022 Initial Submission Date 12/31/2019 Eſective Date 1/1/2020 A. Options for Coverage The state provides Medicaid to speciţed optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper-based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classiţcations of Individuals under Age 21 NEW Children with Non-IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents NEW Optional Targeted Low Income Children APPROVED Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Yes No

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

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0005O | ND-19-0022 Package Header Package ID ND2019MS0005O Submission Type OŰcial Approval Date 8/21/2020 Superseded SPA ID ND-19-0017 User-Entered SPA ID ND-19-0022 Initial Submission Date 12/31/2019 Eſective Date 1/1/2020 B. Medically Needy Options for Coverage The state provides Medicaid to speciţed groups of individuals who are medically needy. The medically needy eligibility groups covered in the state plan are: 1. Mandatory Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Pregnant Women APPROVED Medically Needy Children under Age 18 APPROVED Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Protected Medically Needy Individuals Who Were Eligible in 1973 NEW 2. Optional Medically Needy: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Medically Needy Reasonable Classiţcations of Individuals under Age 21 APPROVED Medically Needy Parents and Other Caretaker Relatives APPROVED Yes No

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

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0005O | ND-19-0022 Package Header Package ID ND2019MS0005O Submission Type OŰcial Approval Date 8/21/2020 Superseded SPA ID ND-19-0017 User-Entered SPA ID ND-19-0022 Initial Submission Date 12/31/2019 Eſective Date 1/1/2020 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Optional Targeted Low Income Children MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0005O | ND-19-0022 Uninsured children who meet the deţnition of optional targeted low income children at 42 C.F.R. §435.4, who have household income at or below a standard established by the state. Package Header Package ID ND2019MS0005O Submission Type OŰcial Approval Date 8/21/2020 Superseded SPA ID ND-13-0017-MM1 User-Entered SPA ID ND-19-0022 Initial Submission Date 12/31/2019 Eſective Date 1/1/2020 The state covers the optional targeted low income children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 19, or a lower age, as speciţed in C. 2. Are uninsured and otherwise meet the deţnition of optional targeted low-income child at 42 CFR 435.4 and section 1905(u)(2)(B) of the Act. 3. Have household income at or below the standard established by the state, if the state has an income standard. 4. Are not otherwise eligible for and enrolled in mandatory coverage under the state plan. B. Financial Methodologies MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. C. Individuals Covered 1. The state covers all children under a speciţed age under this eligibility group. The age of children covered under this eligibility group is: D. Income Standard Used The income standard for this eligibility group is: FPL 170.00% Yes No a. Under age 19 b. Under age 18 c. Under other age

Optional Targeted Low Income Children MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0005O | ND-19-0022 Package Header Package ID ND2019MS0005O Submission Type OŰcial Approval Date 8/21/2020 Superseded SPA ID ND-13-0017-MM1 User-Entered SPA ID ND-19-0022 Initial Submission Date 12/31/2019 Eſective Date 1/1/2020 E. Basis for Income Standard 1. Minimum income standard The minimum income standard for this eligibility group is a standard greater than the lowest income standard currently used for children of this age under the mandatory Infants and Children under Age 19 eligibility group. 2. Maximum income standard b. The state's maximum income standard for this eligibility group is: c. The amount of the maximum income standard is: FPL 170.00% a. The state certiţes that it has submitted and received approval for its converted income standard(s) for this eligibility group to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classiţcation of children under this eligibility group. i. The state's eſective income level for this eligibility group under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. ii. The state's eſective income level for this group of children under the CHIP state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. iii. The state's eſective income level for this eligibility group under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. iv. The state's eſective income level for this group of children under the CHIP state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. v. The state's eſective income level for this group of children under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. vi. The state's eſective income level for this group of children under a CHIP-1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. vii. The state's eſective income level for this group of children under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. viii. The state's eſective income level for this group of children under a CHIP 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. ix. 200% FPL x. A percentage of the FPL which may exceed the Medicaid Applicable Income Level, deţned in section 2110(b)(4), but by no more than 50 percentage points.

Optional Targeted Low Income Children MEDICAID | Medicaid State Plan | Eligibility | ND2019MS0005O | ND-19-0022 Package Header Package ID ND2019MS0005O Submission Type OŰcial Approval Date 8/21/2020 Superseded SPA ID ND-13-0017-MM1 User-Entered SPA ID ND-19-0022 Initial Submission Date 12/31/2019 Eſective Date 1/1/2020 F. Additional Information (optional)

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 8/31/2020 3:13 PM EDT

Records / Submission Packages - View All ND - Submission Package - ND2020MS0001O - (ND-20-0003) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID ND2020MS0001O Program Name N/A SPA ID ND-20-0003 Version Number 3 Submitted By LeeAnn Thiel Package Disposition Priority Code P2 Submission Type Official State ND Region Denver, CO Package Status Approved Submission Date 3/30/2020 Approval Date 9/25/2020 5:31 PM EDT Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter RAI Transaction Logs News Related Actions Page 1 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid & CHIP Operations Group 601 E. 12th Street Kansas City, MO 64106 Center for Medicaid & CHIP Services September 25, 2020 Christopher Jones Executive Director ND Medical Services Dept 325 600 E Boulevard Ave Bismarck, ND 58505 Re: Approval of State Plan Amendment ND-20-0003 Dear Christopher Jones: On March 30, 2020, the Centers for Medicare and Medicaid Services (CMS) received North Dakota State Plan Amendment (SPA) ND-20-0003 to amend the State Plan to increase the eligibility income level for pregnant women to 157% of the Federal Poverty Level. We approve North Dakota State Plan Amendment (SPA) ND-20-0003 on September 25, 2020 with an effective date(s) of January 01, 2020. Name Date Created No items available If you have any questions regarding this amendment, please contact Curtis Volesky at curtis.volesky@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services RAI CMS is issuing this Request for Additional Information (RAI) pursuant to Section 1915(f) of the Social Security Act (added by P.L. 97 -35). This request has the effect of stopping the 90 -day time period for CMS to act on the material. A new 90 day time frame will not begin until we receive your response to this request. In accordance with our guidelines to all State Medicaid directors dated January 2, 2001, and subsequently reiterated in the August 16, 2018 Center for Medicaid and CHIP Services Informational Bulletin, if a response to a formal request for additional information from CMS is not received from the state within 90 days of issuance, CMS will initiate disapproval of the SPA or waiver action. In addition, because this amendment was submitted after January 2, 2001 and is effective after January 1, 2001, please be advised that we will defer federal financial participation (FFP) for state payments made in accordance with this amendment until it is approved. Upon approval, FFP will be available for the period beginning with the effective date through the date of approval. Submission Package ND2020MS0001O Authority Eligibility State ND Agency Name ND Medical Services Submission Date Mar 30, 2020 Priority Code P2 All Questions Page 2 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Question ID Reference CMS question to the State Policy/Regulation State Response 1 Handling Excess Income RU North Dakota has included a Reviewable Unit (RU) relating to the handling of excess income (spenddown). The state’s submission is identical to the submission of this RU in ND 19-0014. Please explain what changes the state seeks to make to this RU or remove the RU from the submission package. 1902(a)(17), 1902(f), 435.121 The Reviewable Unit has been removed. 2 MAGI Based Methodologies RU North Dakota has included the MAGI Based Methodologies Reviewable Unit in the SPA. Please explain whether the state intends to make changes to the current MAGI- based methodologies. If no changes are proposed, it is not necessary to include the RU in the SPA. The state may choose to remove or keep the RU in the submission package. 1902(e)(14), 435.603 The Reviewable Unit has been removed. 3 Medically Needy RUs Please clarify whether it is the intent of this state plan amendment to make changes to North Dakota’s medically needy program. If the state does not intend to make changes to its medically needy income or resource levels, or to any medically needy eligibility group, these Reviewable Units (RU) may be removed from the submission package. Specifically, we request additional information on the following elements of the state plan amendment submission: 1. North Dakota has included in the SPA an RU relating to the medically needy income level (MNIL). Please explain what changes to the MNIL the state intends to make to its current MNIL or remove the RU from the submission package. Citations: 1902(a)(10)(C), 1902(a)(17), 1903(f), 435.811 2. North Dakota has included in the SPA 1902(a)(10)(C)(ii)(II), 435.301(b)(1) The Reviewable Units relating to medically needy have been removed. Page 3 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Question ID Reference CMS question to the State Policy/Regulation State Response an RU relating to the medically needy resource level. Please explain what changes to the medically needy resource level the state intends to make to its current medically needy resource level or remove the RU from the submission package. Citations: 1902(a)(10)(C), 1902(a)(17), 1903(f), 435.811 3. North Dakota has included in the SPA an RU relating to medically needy pregnant women. Please explain what changes the state intends to make to the financial standards or methodologies applicable to this eligibility group with this state plan amendment or remove the RU from the submission package. 4 Non-MAGI methodologies RU North Dakota has included a Reviewable Unit (RU) relating to its non-MAGI methodologies. The state’s submission is identical to the submission of this RU in ND 19-0014. Please explain what changes the state seeks to make to this RU or remove the RU from the submission package. 42 CFR 435.601 The Reviewable Unit has been removed. Submission Package was updated by the State in accordance with the response above Yes No Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2020MS0001O | ND-20-0003 Package Header Package ID ND2020MS0001O Submission Type Official Approval Date 9/25/2020 Superseded SPA ID N/A SPA ID ND-20-0003 Initial Submission Date 3/30/2020 Effective Date N/A State Information State/Territory Name: North Dakota Medicaid Agency Name: ND Medical Services Submission Component State Plan Amendment Medicaid Page 4 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

CHIP Page 5 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2020MS0001O | ND-20-0003 Package Header Package ID ND2020MS0001O Submission Type Official Approval Date 9/25/2020 Superseded SPA ID N/A SPA ID ND-20-0003 Initial Submission Date 3/30/2020 Effective Date N/A SPA ID and Effective Date SPA ID ND-20-0003 Reviewable Unit Proposed Effective Date Superseded SPA ID Mandatory Eligibility Groups 1/1/2020 19-0017 Pregnant Women 1/1/2020 ND-13-0017 Page 6 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2020MS0001O | ND-20-0003 Package Header Package ID ND2020MS0001O Submission Type Official Approval Date 9/25/2020 Superseded SPA ID N/A SPA ID ND-20-0003 Initial Submission Date 3/30/2020 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives Amends the State Plan to increase the eligibility income level for pregnant women to 157% of the FPL effective January 1, 2020. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2020 $407998 Second 2021 $543984 Federal Statute / Regulation Citation 42 CFR 435.116 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available Page 7 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | ND2020MS0001O | ND-20-0003 Package Header Package ID ND2020MS0001O Submission Type Official Approval Date 9/25/2020 Superseded SPA ID N/A SPA ID ND-20-0003 Initial Submission Date 3/30/2020 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other Describe Authority to prepare and submit Medicaid State Plans is provided to the Medicaid single state agency Page 8 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | ND2020MS0001O | ND-20-0003 Package Header Package ID ND2020MS0001O Submission Type Official Approval Date 9/25/2020 Superseded SPA ID N/A SPA ID ND-20-0003 Initial Submission Date 3/30/2020 Effective Date N/A Indicate whether public comment was solicited with respect to this submission. Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Page 9 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | ND2020MS0001O | ND-20-0003 Package Header Package ID ND2020MS0001O Submission Type Official Approval Date 9/25/2020 Superseded SPA ID N/A SPA ID ND-20-0003 Initial Submission Date 3/30/2020 Effective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state Yes No This state plan amendment is likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Yes No  The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner:  All Indian Health Programs Date of solicitation/consultation: Method of solicitation/consultation: 7/26/2019 letter 8/20/2019 tribal consultation meeting 7/1/2019 letter All Urban Indian Organizations States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below:  All Indian Tribes Date of consultation: Method of consultation: 7/1/2019 letter 7/26/2019 letter 8/20/2019 tribal consultation meeting The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Page 10 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Name Date Created Kirstin Michel 3/27/2020 11:09 AM EDT Kirsten Michel 3/27/2020 11:09 AM EDT Attendee List 3/27/2020 11:09 AM EDT Indicate the key issues raised (optional) Access Quality Cost Payment methodology Eligibility Benefits Service delivery Other issue Page 11 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2020MS0001O | ND-20-0003 Package Header Package ID ND2020MS0001O Submission Type Official Approval Date 9/25/2020 Superseded SPA ID 19-0017 User-Entered SPA ID ND-20-0003 Initial Submission Date 3/30/2020 Effective Date 1/1/2020 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women APPROVED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children NEW Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Individuals in 209(b) States Who Are Age 65 or Older or Who have Blindness or a Disability APPROVED Closed Eligibility Groups NEW NEW             Page 12 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Individuals Deemed To Be Receiving SSI Working Individuals under 1619(b) NEW Qualified Medicare Beneficiaries APPROVED Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries APPROVED Qualifying Individuals APPROVED      Page 13 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | ND2020MS0001O | ND-20-0003 Package Header Package ID ND2020MS0001O Submission Type Official Approval Date 9/25/2020 Superseded SPA ID 19-0017 User-Entered SPA ID ND-20-0003 Initial Submission Date 3/30/2020 Effective Date 1/1/2020 B. The state elects the Adult Group, described at 42 CFR 435.119. Yes No Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Adult Group CONVERTED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A  Page 14 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | ND2020MS0001O | ND-20-0003 Women who are pregnant or post-partum, with household income at or below a standard established by the state. Package Header Package ID ND2020MS0001O Submission Type Official Approval Date 9/25/2020 Superseded SPA ID ND-13-0017 System-Derived SPA ID ND-20-0003 Initial Submission Date 3/30/2020 Effective Date 1/1/2020 The state covers the mandatory pregnant women group in accordance with the following provisions: A. Characteristics 1. Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. 2. 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 C.F.R. 435.110. Yes No B. Financial Methodologies MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. C. Income Standard Used The state uses the following income standard for this group: FPL 157.00% Page 15 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | ND2020MS0001O | ND-20-0003 Package Header Package ID ND2020MS0001O Submission Type Official Approval Date 9/25/2020 Superseded SPA ID ND-13-0017 System-Derived SPA ID ND-20-0003 Initial Submission Date 3/30/2020 Effective Date 1/1/2020 D. Benefits for Pregnant Women Benefits for individuals in this eligibility group consist of the following: 1. All pregnant women eligible under this group receive full Medicaid coverage under this state plan. 2. Pregnant women whose income exceeds the income limit specified for full coverage of pregnant women receive only pregnancy-related services. Page 16 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | ND2020MS0001O | ND-20-0003 Package Header Package ID ND2020MS0001O Submission Type Official Approval Date 9/25/2020 Superseded SPA ID ND-13-0017 System-Derived SPA ID ND-20-0003 Initial Submission Date 3/30/2020 Effective Date 1/1/2020 E. Basis for Pregnant Women Income Standard 1. Minimum income standard 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. Yes No b. The minimum income standard for this eligibility group is 133% FPL. 2. Maximum income standard  a. 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. b. The state's maximum income standard for this eligibility group is: i. 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)(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. ii. 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)(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 December 31, 2013, converted to a MAGI-equivalent percent of FPL. iii. 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. iv. 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. v. 185% FPL G. Additional Information (optional) Page 17 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 9/30/2020 1:38 PM EDT Page 18 of 18 Medicaid State Plan Print View 09/30/2020 https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwX...

Table of Contents

State/Territory Name: North Dakota State Plan Amendment (SPA) #: 20-0004 This file contains the following documents in the order listed:

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

TN: ND-20-0004 Approval Date: 06/16/2020 Effective Date: 01/01/2020

DEPARTMENT OFHEALTH & HUMAN SERVICES Centers forMedicare & Medicaid Services 601East12thStreet, Suite 355 Kansas City, Missouri 64106-2898 Medicaid andCHIPOperations Group June16, 2020 Caprice Knapp, Medicaid Director Division ofMedical Services NorthDakota Department ofHuman Services 600EastBoulevard Avenue, Dept. 325 Bismarck, ND 58505-0250 DearMs. Knapp: Wehavereviewed theproposed State PlanAmendment (SPA) submitted undertransmittal number (TN) 20-0004. Thisamendment updates thestate’sAlternative Benefits Plan (ABP) for theadultgroup. Please beinformed thatthisStatePlanAmendment wasapproved June16, 2020, withan effective dateofJanuary 1, 2020. Weareenclosing theCMS-179andtheamended planpage(s). Ifyouhaveanyquestions concerning thisamendment, please contact Curtis Volesky at 303) 844-7033. Sincerely, X JamesG. Scott, Director Division ofProgram Operations Enclosures cc: Krista Fremming, North Dakota Stacey Koehly, North Dakota

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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 April 8, 2020 Caprice Knapp, Medicaid Director Division of Medical Services North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250 Re: North Dakota State Plan Amendment (SPA) 20-0009 Dear Ms. Knapp: 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. The State of North Dakota requested a modification of the requirement to submit SPAs related to the COVID-19 emergency by March 31, 2020, to obtain a SPA effective date during the first calendar

quarter of 2020, pursuant to 42 C.F.R. §430.20. CMS is approving this request pursuant to section 1135(b)(5) of the Act.

The State of North Dakota also requested a waiver of public notice requirements applicable to the state plan amendment (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 ABPs. These requirements help to ensure that the affected public has reasonable opportunity to comment on these SPAs. CMS recognizes that during this public health emergency, North Dakota must act expeditiously to protect and serve the general public. Therefore, under section 1135(b)(1)(C) and 1135(b)(5) of the Act, CMS is approving the state’s request to waive these notice requirements applicable to this SPA.

The State of North Dakota 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 Dakota’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.

These approvals under section 1135 only apply with respect to SPAs that provide or increase beneficiary access to items and services related to COVID-19 (such as cost sharing waivers, payment rate increases, or amendments to ABPs to add services or providers) and that would not restrict or limit payment or services or otherwise burden beneficiaries and providers, and that are temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 emergency (or any extension thereof). Even though CMS is approving this waiver, we encourage the state to make all relevant information 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 Dakota’s Medicaid SPA Transmittal Number 20-0009 is approved effective March 1, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Curtis Volesky at 303-844-7033, or by email at Curtis.volesky@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 Dakota 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: 2020.04.08 17:22:53 -04'00'

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State/Territory: _North Dakota__ TN: __20-0009_______ Approval Date: __________ Supersedes TN: ___NEW____ Effective Date: 03-01-2020 89.a 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: Describe shorter period here. 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). ϰͬϴͬϮϬ

State/Territory: _North Dakota__ TN: __20-0009_______ Approval Date: __________ Supersedes TN: ___NEW____ Effective Date: 03-01-2020 89.b c. __X__ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in North Dakota Medicaid state plan, as described below: North Dakota did not do tribal consultation prior to submission to this SPA but will do written tribal consultation within two weeks of submitting this SPA. Section A – Eligibility 1. _____ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. Include name of the optional eligibility group and applicable income and resource standard. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ -or-

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

State/Territory: _North Dakota__ TN: __20-0009_______ Approval Date: __________ Supersedes TN: ___NEW____ Effective Date: 03-01-2020 89.c 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. ϰͬϴͬϮϬ

State/Territory: _North Dakota__ TN: __20-0009_______ Approval Date: __________ Supersedes TN: ___NEW____ Effective Date: 03-01-2020 89.d 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. __ __ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: 2. __X__ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. __X__ The following eligibility groups or categorical populations: ϰͬϴͬϮϬ

State/Territory: _North Dakota__ TN: __20-0009_______ Approval Date: __________ Supersedes TN: ___NEW____ Effective Date: 03-01-2020 89.e Individuals covered under the TWWIIA coverage group (1902(a)(10)(A)(ii)(XV)), and individuals covered under the Family Opportunity Act (1902(a)(10)(A)(ii)(XIX). 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship. Section D – Benefits Benefits: 1. _____ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. _____ The agency makes the following adjustments to benefits currently covered in the state plan: 3. _____ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Please describe. ϰͬϴͬϮϬ

State/Territory: _North Dakota__ TN: __20-0009_______ Approval Date: __________ Supersedes TN: ___NEW____ Effective Date: 03-01-2020 89.f Telehealth: 5. _____ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Please describe. Drug Benefit: 6. __X__ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. For medications that are currently limited to a 34 day supply, ND Medicaid may allow a one-time 90 day fill to decrease the need for individuals to visit providers. 7. __X__ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. __ __ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. Please describe the manner in which professional dispensing fees are adjusted. 9. __X__ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. _____ Newly added benefits described in Section D are paid using the following methodology: a. _____ Published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ ϰͬϴͬϮϬ

State/Territory: _North Dakota__ TN: __20-0009_______ Approval Date: __________ Supersedes TN: ___NEW____ Effective Date: 03-01-2020 89.g b. _____ Other: Describe methodology here. Increases to state plan payment methodologies: 2. _____ The agency increases payment rates for the following services: Please list all that apply. a. _____ Payment increases are targeted based on the following criteria: Please describe criteria. b. Payments are increased through: i. _____ A supplemental payment or add-on within applicable upper payment limits: Please describe. ii. _____ An increase to rates as described below. Rates are increased: _____ Uniformly by the following percentage: _____________ _____ Through a modification to published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ _____ Up to the Medicare payments for equivalent services. _____ By the following factors: Please describe. ϰͬϴͬϮϬ

State/Territory: _North Dakota__ TN: __20-0009_______ Approval Date: __________ Supersedes TN: ___NEW____ Effective Date: 03-01-2020 89.h Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the state authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid state plan; b. _____ Differ from payments for the same services when provided face to face; c. _____ Differ from current state plan provisions governing reimbursement for telehealth; Describe telehealth payment variation. d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. __ __ Other payment changes: Please describe. Section F – Post-Eligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: 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.) ϰͬϴͬϮϬ

State/Territory: _North Dakota__ TN: __20-0009_______ Approval Date: __________ Supersedes TN: ___NEW____ Effective Date: 03-01-2020 89.i The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information North Dakota may suspend the Qualified Service Provider qualifications regarding competency and state criteria, waive the timelines for nursing facility rate reconsiderations and appeals, and waive the 15 day limit for payment for a reserved bed for an inpatient hospitalization for a resident of a nursing facility or intermediate care facility for individuals with an intellectual disability if the hospital stay is due to a diagnosis of COVID-19. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870. ϰͬϴͬϮϬ

Table of Contents

State/Territory Name: North Dakota State Plan Amendment (SPA) #: 20-0022 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th Street, Suite 355 Kansas City, MO 64106 Medicaid & CHIP Operations Group August 26, 2020 Caprice Knapp, Medicaid Director Division of Medical Services North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250 RE: North Dakota State Plan Amendment (SPA) 20-0022 Dear Ms. Knapp: We have reviewed the State Plan Amendment (SPA) submitted under transmittal number 20- 0022. This SPA amends the State Plan to update the Standards for the Coverage of Organ Transplant Services. Please be informed that this SPA was approved on August 14, 2020, with an effective date of July 1, 2020. Enclosed are the CMS-179 and the amended plan pages. Should you have any questions about this amendment, please contact Curtis Volesky at (303) 844-7033. Sincerely, James *Scott, Director Division of Program Operations cc: Krista Fremming, krfremming@nd.gov Stacey Koehly, skoehly@nd.gov Digitally signed by James G. Scott -S Date: 2020.08.26 17:42:19 -05'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO. 0938-0193 FORM CMS-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 1. TRANSMITTAL NUMBER: 20-0022 2. STATE North Dakota 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE July 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: 1903(i)(1) of the Act 7. FEDERAL BUDGET IMPACT: a. FFY 2020 $ 0 b. FFY 2021 $ 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Section 3, Page 27 Attachment 3.1-E, Page 1 Attachment to Page 2 of Attachment 3.1-A, page 1 of 2 Attachment to Page 2 of Attachment 3.1-B, page 2 of 3 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Section 3, Page 27 (TN 87-8) Attachment 3.1-E, Page 1 (TN 88-5) Attachment to Page 2 of Attachment 3.1-A, page 1 of 2 (TN 04-004) Attachment to Page 2 of Attachment 3.1-B, page 2 of 3 (TN 03-012B) 10. SUBJECT OF AMENDMENT: Amends the State Plan to update the Standards for the Coverage of Organ Transplant Services. 11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Caprice Knapp, Director, NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Medical Services Division 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Caprice Knapp, Director Medical Services Division ND Department of Human Services 600 East Boulevard Avenue Dept 325 Bismarck ND 58505-0250 13. TYPED NAME: Caprice Knapp 14. TITLE: Director, Medical Services Division 15. DATE SUBMITTED: July 22, 2020 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: -XO\       $XJXVW -XO\     -DPHV*6FRWW      'LUHFWRU'LYLVLRQRI3URJUDP2SHUDWLRQV Digitally signed by James G. Scott -S Date: 2020.08.26 17:42:50 -05'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO. 0938-0193 FORM CMS-179 (07-92) 23. REMARKS:

TN No. 20-0022 Approval Date: Effective Date: 07-01-2020 Supersedes TN No: 87-8 Revision: HCFA-PM-87-5 APRIL 1987 27 0MB No.: 0938-0193 State/Territory: North Dakota Citation 3.1 (f) (1) Optometric Services 42 CFR 441.30 AT-78-90 1903 (i) (l) of the Act, P.L. 99-272 (Section 9507) Optometric services (other than those provided under §§435.531 and 436.531) are not now but were previously provided under the plan. Services of the type an optometrist is legally authorized to perform are specifically included in the term "physicians' services" under this plan and are reimbursed whether furnished by a physician or an optometrist. Ƒ Yes. Ƒ No. The conditions described in the first sentence apply but the term "physicians' services" does not specifically include services of the type an optometrist is legally authorized to perform. Not applicable. The conditions in the first sentence do not apply. (2) Organ Transplant Procedures Organ transplant procedures are provided. Ƒ No. Yes. Similarly situated individuals are treated alike and any restriction on the facilities that may, or practitioners who may, provide those procedures is consistent with the accessibility of high- quality care to individuals eligible for the procedures under this plan. Standards for the coverage of organ transplant procedures are described at ATTACHMENT 3.1-E. 

TN No. 20-0022 Approval Date: __ ___ Effective Date: 07-01-2020 Supersedes TN No: 88-5 Revision: HCFA-PM-87-4 (BERC) Attachment 3.1-E March 1987 Page 1 OMB No. 0938-0193 NORTH DAKOTA State/Territory: STANDARDS FOR THE COVERAGE OF ORGAN TRANSPLANT SERVICES 1. Authorization is required prior to transplants that occur outside of North Dakota. Medicaid coverage is limited to approved services rendered during periods when the member is eligible for ND Medicaid. 2. All transplantation services must: a. be medically necessary and not experimental; b. ensure similarly situated individuals are treated alike; c. ensure any restriction, on the facilities or practitioners which may provide such procedures, is consistent with the accessibility of high-quality care to individuals eligible for the procedures under the State plan; and d. ensure services are reasonable in amount, duration and scope to achieve their purpose. 3. Procedure must anticipate prolonging life, maintaining or improving quality of life, and be ethically acceptable. 4. A referral from an enrolled in-state Medicaid practitioner must be made for the member to be evaluated at an out-of-state transplant facility. After the out-of-state transplant facility completes its evaluation of the member and determines the member is a qualified candidate for the transplant, an enrolled Medicaid practitioner must make a referral for the transplant procedure. 5. All organ transplant programs must be located in a hospital that has a Medicare provider agreement and comply with all Medicare requirements for organ transplants. 6. Coverage includes medically necessary transplants and related services. Related services include items such as cadaveric or living donor expenses; organ procurement costs, tissue typing, and searches and matches. 

TN No. 20-0022 Approval Date: __ ___ Effective Date: 07-01-2020 Supersedes TN No: 04-004 State: North Dakota Attachment to Page 2 of Attachment 3.1-A Page 1 of 2 LIMITATIONS ON AMOUNT, DURATION AND SCOPE 5.a. Physician services. We limit enrollment to physicians meeting the requirements contained in 4752(e) of OBRA 1990 for physician services provided on or after January 1, 1992 to children and pregnant women. Payment for abortions will be limited to those abortions where payment is necessary to comply with the March 15, 1995 Order of the United States District Court in Fargo Women's Health Organization, Inc., v. Henry C. Wessman, Civil No. A3-94-36. The court order is based on the court's decision that the current Hyde Amendment language requires State Medicaid Programs to pay for abortions to save the life of the mother or that are a result of an act of rape or incest. 

TN No. 20-0022 Approval Date: __ ___ Effective Date: 07-01-2020 Supersedes TN No: 03-012B State: North Dakota Attachment to Page 2 of Attachment 3.1-B Page 2 of 3 VACATED 

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: 20-0023 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th Street, Suite 355 Kansas City, MO 64106

Medicaid & CHIP Operations Group

October 7, 2020

Caprice Knapp, Medicaid Director Division of Medical Services North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250

RE: North Dakota State Plan Amendment (SPA) 20-0023

Dear Ms. Knapp:

We have reviewed the State Plan Amendment (SPA) submitted under transmittal number 20- 0023. This SPA amends the State Plan to update the criteria for Targeted Case Management for Pregnant Women and Infants and updates the provider qualifications.

Please be informed that this SPA was approved on October 6, 2020, with an effective date of July 1, 2020. Enclosed is the CMS-179 and SPA pages.

Should you have any questions about this amendment, please contact Curtis Volesky at (303) 844-7033.

Sincerely,

James G. Scott, Director Division of Program Operations

cc: Krista Fremming, krfremming@nd.gov Stacey Koehly, skoehly@nd.gov LeeAnn Thiel, lthiel@nd.gov

Digitally signed by James G. Scott -S Date: 2020.10.07 18:19:32 -05'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO. 0938-0193 FORM CMS-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 1. TRANSMITTAL NUMBER: 20-0023 2. STATE North Dakota 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE July 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: 42 CFR 440.169 7. FEDERAL BUDGET IMPACT: a. FFY 2020 $1,750 b. FFY 2021 $6,250 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Supplement 2 to Attachment 3.1-A Pages 1-8 Supplement 2 to Attachment 3.1-B Pages 1-8 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Supplement 2 to Attachment 3.1-A Pages 1-9 (TN 08-006) Supplement 2 to Attachment 3.1-B Pages 1-9 (TN 08-006) 10. SUBJECT OF AMENDMENT: Amends the State Plan to update the criteria for Targeted Case Management for Pregnant Women and Infants and updates the provider qualifications. 11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Caprice Knapp, Director NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Medical Services Division 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Caprice Knapp, Director Medical Services Division ND Department of Human Services 600 East Boulevard Avenue Dept 325 Bismarck ND 58505-0250 13. TYPED NAME: Caprice Knapp 14. TITLE: Director, Medical Services Division 15. DATE SUBMITTED: Original Date: July 23, 2020 Resubmission Date: October 1, 2020 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGN EGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: -XO\        2FWREHU -XO\ -DPHV*6FRWW      'LUHFWRU'LYLVLRQRI3URJUDP2SHUDWLRQV Digitally signed by James G. Scott -S Date: 2020.10.07 18:20:12 -05'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO. 0938-0193 FORM CMS-179 (07-92) 23. REMARKS:

Supplement 2 to Attachment 3.1-A Page 1 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 Target Group (42 Code of Federal Regulations 441.18(a)(8)(i) and 441.18(a)(9)): The criteria for the Target Group for Targeted Case Management (TCM) Services for Pregnant Women and Infants are: 1. Be Medicaid eligible; 2. Determined to be pregnant by medical personnel, a public health agency, or a home pregnancy test. The woman must meet at least one of the following at risk criteria: a. Is age 17 or younger at the time of the assessment; b. Is age 35 or older at the time of the assessment; c. Uses any alcohol during current pregnancy. d. Uses illegal drugs; e. Abuses prescription drugs; f. Previous preterm delivery (before 37 weeks of pregnancy), low birth weight (less than 5 pounds, 8 ounces) or still birth; g. Last birth within one year; h. Multi-fetal gestation - more than one fetus in current pregnancy; i. Uses any tobacco products during current pregnancy; j. Has a developmental disability; k. Has a medical condition such as diabetes, AIDS, HIV, high blood pressure, asthma, anemia, Polycystic ovary syndrome (PCOS), hemorrhagic condition, gestational diabetes, kidney disease, autoimmune disease, thyroid disease, obesity, sexually transmitted disease (STD), ZIKA infection or a heart condition. A woman would qualify as a high-risk of a problem pregnancy if a medical practitioner has certified that a particular medical condition could result in a high-risk pregnancy for the woman; l. Is currently being treated for a mental health disorder or is currently on any psychotropic drugs; m. Known birth defects or genetic conditions in the fetus. 3. Women may also qualify for TCM services if three or more of the following factors are present: a. Has been diagnosed, within the last five years, with a mental health disorder; b. Psychotropic medication use within the last five years; c. Has had a previous high-risk pregnancy; d. Has a family history of genetic disorders that could be passed on to the child; 

Supplement 2 to Attachment 3.1-A Page 2 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 e. Is currently homeless or has had three different living situations during the current pregnancy; f. Has experienced family violence including spousal abuse, child abuse and neglect or sexual abuse; g. Has experienced sexual assault within the last two years; h. Is isolated from a network of people who provide an individual with practical or emotional support; i. Has not initiated prenatal care and pregnancy is in the second or third trimester; j. Has not graduated from high school or received her GED; k. Has two or more children under the age of 5; l. Is residing in any group living arrangement such as a group foster care, residential treatment center or alcohol treatment center; m. First pregnancy; n. Has not visited a dentist in the last year; o. Has been released from a correctional facility within the last six months. 4. For continuing services after the birth of the child, the woman must be living with and providing the primary support system for her infant. Participation in the program ends the last day of the month in which an infant reaches 6 months of age. Target group includes individuals transitioning to a community setting. Case- management services will be made available for up to 60 consecutive days of a covered stay in a medical institution. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions. Areas of State in which services will be provided (§1915(g)(1) of the Act): Entire State Only in the following geographic areas: [Specify areas] Comparability of services (§§1902(a)(10)(B) and 1915(g)(1)) Services are provided in accordance with §1902(a)(10)(B) of the Act. Services are not comparable in amount duration and scope (§1915(g)(1)). 

Supplement 2 to Attachment 3.1-A Page 3 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 Definition of services (42 CFR 440.169): Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services. Targeted Case Management includes the following assistance: ™ Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include: x taking individual’s history; x identifying the individual’s needs and completing related documentation; and x gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual; Assessments for TCM for High Risk Pregnant Women are allowed once per pregnancy. The number of assessments may be increased based on medical necessity. ™ Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that: x specifies the goals and actions to address the medical, social, educational, and other services needed by the individual; x includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual’s authorized health care decision maker) and others to develop those goals; and x identifies a course of action to respond to the assessed needs of the eligible individual; ™ Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including: x activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan such as making referrals to providers and scheduling appointments for the individual. ™ Monitoring and follow-up activities: x activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual’s needs, and which may be with 

Supplement 2 to Attachment 3.1-A Page 4 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met: o services are being furnished in accordance with the individual’s care plan; o services in the care plan are adequate; and o changes in the needs or status of the individual are reflected in the care plan. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers. Case monitoring consists of regular contacts between the case manager and the recipient to assist with meetings the goals outlined in the case plan. Monitoring also includes the identification and resolution of daily problems and ongoing assessment of the case plan to determine if the services are meeting the needs of the recipient. The ultimate goal of the targeted case management services for pregnant women is a positive birth outcome and healthy start for the infant. Case Monitoring should be conducted at a minimum of monthly and must include two face-to-face contacts in the recipient's residence during pregnancy. Case management includes contacts with non-eligible individuals that are directly related to identifying the eligible individual’s needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual’s needs. (42 CFR 440.169(e)) Case management services are coordinated with and do not duplicate activities provided as part of institutional services and discharge planning activities. Qualifications of Providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)): In order to meet the above needs the following providers are available to at risk pregnant women. Agency Providers: Generic Qualifications for providers serving at risk pregnant women; 

Supplement 2 to Attachment 3.1-A Page 5 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 Case Managers for pregnant women and their infants up to 6 months of age is limited to providers who: 1. Have at least six months experience in delivering services in a community or home setting. 2. Demonstrate the ability to coordinate prenatal care services for individuals, develop relationships with health care and other area agencies in the particular geographical area they are serving, demonstrate experience in assessing the needs of pregnant women and developing case management plans based on the needs of clients and must demonstrate ability to evaluate an at risk pregnant woman's progress in obtaining appropriate medical care and other needed services. 3. Ensure case management staff supervisors have a minimum of a degree in social work, nursing, education, and have at least three years experience in service delivery and supervision. 4. Have in place a training process that will ensure that staff have adequate knowledge relating to at risk pregnancy, parenting and other important issues. 5. Demonstrate the ability to provide 24-hour, 7 day a week crisis services to eligible women who are in need of emergency case management services. Individuals performing case management services for this category must meet one of the following criteria: 1. An individual with a master's degree in social work. 2. A licensed baccalaureate social worker and at least six months of case management experience. 3. A registered nurse licensed in accordance with the North Dakota Nurse Practice Act. 4. A licensed practical nurse licensed in accordance with the North Dakota Nurse Practice Act and has at least six months of case management experience. 5. A health educator with at least a bachelor’s degree and at least six months of case management experience. 

Supplement 2 to Attachment 3.1-A Page 6 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 6. Licensed Registered Dietitians or Licensed Nutritionists, licensed by the North Dakota Board of Dietetics Practice. 7. If the individual does not have a bachelor’s degree, they will be allowed to enroll to provide TCM if they have at least five years of experience working with high risk pregnant women in a supervised, clinical setting. 8. Individuals enrolled and providing targeted case management prior to July 1, 2020 will be deemed qualified to provide targeted case management, as long as they remain actively providing targeted case management services. Freedom of Choice (42 CFR 441.18(a)(1)): The State assures that the provision of case management services will not restrict an individual’s free choice of providers in violation of section 1902(a)(23) of the Act. 1. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan. 2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan. Freedom of Choice Exception (§1915(g)(1) and 42 CFR 441.18(b)): Target group consists of eligible individuals with developmental disabilities or with chronic mental illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental illness receive needed services: Access to Services (42 CFR 441.18(a)(2), 42 CFR 441.18(a)(3), 42 CFR 441.18(a)(6)): The State assures the following: x Case management (including targeted case management) services will not be used to restrict an individual’s access to other services under the plan. x Individuals will not be compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management) services; and 

Supplement 2 to Attachment 3.1-A Page 7 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 x Providers of case management services do not exercise the agency’s authority to authorize or deny the provision of other services under the plan. For plans that provide case management services to assist individuals who reside in medical institutions to transition to the community, the State makes the following assurances: x The State assures that the amount, duration, and scope of the case management activities would be documented in an individual's plan of care which includes case management activities prior to and post-discharge, to facilitate a successful transition to the community. x The State assures that case management is only provided by and reimbursed to community case management providers. x The State assures that Federal Financial Participation is only available to community providers and will not be claimed on behalf of an individual until discharge from the medical institution and enrollment in community services. Payment (42 CFR 441.18(a)(4)): Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. Case Records (42 CFR 441.18(a)(7)): Providers maintain case records that document for all individuals receiving case management as follows: (i)The name of the individual; (ii) The dates of the case management services; (iii)The name of the provider agency and the person providing the case management service; (iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; (v) Whether the individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan. Limitations: Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §441.169 when the case management activities are an integral and inseparable component of another covered Medicaid service (State Medicaid Manual (SMM) 4302.F). 

Supplement 2 to Attachment 3.1-A Page 8 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §441.169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c)) FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that is included in an individualized education program or individualized family service plan consistent with §1903(c) of the Act. (§§1902(a)(25) and 1905(c)) 

Supplement 2 to Attachment 3.1-B Page 1 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 Target Group (42 Code of Federal Regulations 441.18(a)(8)(i) and 441.18(a)(9)): The criteria for the Target Group for Targeted Case Management (TCM) Services for Pregnant Women and Infants are: 1. Be Medicaid eligible; 2. Determined to be pregnant by medical personnel, a public health agency, or a home pregnancy test. The woman must meet at least one of the following at risk criteria: a. Is age 17 or younger at the time of the assessment; b. Is age 35 or older at the time of the assessment; c. Uses any alcohol during current pregnancy. d. Uses illegal drugs; e. Abuses prescription drugs; f. Previous preterm delivery (before 37 weeks of pregnancy), low birth weight (less than 5 pounds, 8 ounces) or still birth; g. Last birth within one year; h. Multi-fetal gestation - more than one fetus in current pregnancy; i. Uses any tobacco products during current pregnancy; j. Has a developmental disability; k. Has a medical condition such as diabetes, AIDS, HIV, high blood pressure, asthma, anemia, Polycystic ovary syndrome (PCOS), hemorrhagic condition, gestational diabetes, kidney disease, autoimmune disease, thyroid disease, obesity, sexually transmitted disease (STD), ZIKA infection or a heart condition. A woman would qualify as a high-risk of a problem pregnancy if a medical practitioner has certified that a particular medical condition could result in a high-risk pregnancy for the woman; l. Is currently being treated for a mental health disorder or is currently on any psychotropic drugs; m. Known birth defects or genetic conditions in the fetus. 3. Women may also qualify for TCM services if three or more of the following factors are present: a. Has been diagnosed, within the last five years, with a mental health disorder; b. Psychotropic medication use within the last five years; c. Has had a previous high-risk pregnancy; d. Has a family history of genetic disorders that could be passed on to the child; 

Supplement 2 to Attachment 3.1-B Page 2 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 e. Is currently homeless or has had three different living situations during the current pregnancy; f. Has experienced family violence including spousal abuse, child abuse and neglect or sexual abuse; g. Has experienced sexual assault within the last two years; h. Is isolated from a network of people who provide an individual with practical or emotional support; i. Has not initiated prenatal care and pregnancy is in the second or third trimester; j. Has not graduated from high school or received her GED; k. Has two or more children under the age of 5; l. Is residing in any group living arrangement such as a group foster care, residential treatment center or alcohol treatment center; m. First pregnancy; n. Has not visited a dentist in the last year; o. Has been released from a correctional facility within the last six months. 4. For continuing services after the birth of the child, the woman must be living with and providing the primary support system for her infant. Participation in the program ends the last day of the month in which an infant reaches 6 months of age. Target group includes individuals transitioning to a community setting. Case- management services will be made available for up to 60 consecutive days of a covered stay in a medical institution. The target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions. Areas of State in which services will be provided (§1915(g)(1) of the Act): Entire State Only in the following geographic areas: [Specify areas] Comparability of services (§§1902(a)(10)(B) and 1915(g)(1)) Services are provided in accordance with §1902(a)(10)(B) of the Act. Services are not comparable in amount duration and scope (§1915(g)(1)). 

Supplement 2 to Attachment 3.1-B Page 3 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 Definition of services (42 CFR 440.169): Targeted case management services are defined as services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services. Targeted Case Management includes the following assistance: ™ Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include: x taking individual’s history; x identifying the individual’s needs and completing related documentation; and x gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual; Assessments for TCM for High Risk Pregnant Women are allowed once per pregnancy. The number of assessments may be increased based on medical necessity. ™ Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that: x specifies the goals and actions to address the medical, social, educational, and other services needed by the individual; x includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual’s authorized health care decision maker) and others to develop those goals; and x identifies a course of action to respond to the assessed needs of the eligible individual; ™ Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including: x activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan such as making referrals to providers and scheduling appointments for the individual. ™ Monitoring and follow-up activities: x activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual’s needs, and which may be with 

Supplement 2 to Attachment 3.1-B Page 4 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met: o services are being furnished in accordance with the individual’s care plan; o services in the care plan are adequate; and o changes in the needs or status of the individual are reflected in the care plan. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers. Case monitoring consists of regular contacts between the case manager and the recipient to assist with meetings the goals outlined in the case plan. Monitoring also includes the identification and resolution of daily problems and ongoing assessment of the case plan to determine if the services are meeting the needs of the recipient. The ultimate goal of the targeted case management services for pregnant women is a positive birth outcome and healthy start for the infant. Case Monitoring should be conducted at a minimum of monthly and must include two face-to-face contacts in the recipient's residence during pregnancy. Case management includes contacts with non-eligible individuals that are directly related to identifying the eligible individual’s needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual’s needs. (42 CFR 440.169(e)) Case management services are coordinated with and do not duplicate activities provided as part of institutional services and discharge planning activities. Qualifications of Providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)): In order to meet the above needs the following providers are available to at risk pregnant women. Agency Providers: Generic Qualifications for providers serving at risk pregnant women; 

Supplement 2 to Attachment 3.1-B Page 5 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 Case Managers for pregnant women and their infants up to 6 months of age is limited to providers who: 1. Have at least six months experience in delivering services in a community or home setting. 2. Demonstrate the ability to coordinate prenatal care services for individuals, develop relationships with health care and other area agencies in the particular geographical area they are serving, demonstrate experience in assessing the needs of pregnant women and developing case management plans based on the needs of clients and must demonstrate ability to evaluate an at risk pregnant woman's progress in obtaining appropriate medical care and other needed services. 3. Ensure case management staff supervisors have a minimum of a degree in social work, nursing, education, and have at least three years experience in service delivery and supervision. 4. Have in place a training process that will ensure that staff have adequate knowledge relating to at risk pregnancy, parenting and other important issues. 5. Demonstrate the ability to provide 24-hour, 7 day a week crisis services to eligible women who are in need of emergency case management services. Individuals performing case management services for this category must meet one of the following criteria: 1. An individual with a master's degree in social work. 2. A licensed baccalaureate social worker and at least six months of case management experience. 3. A registered nurse licensed in accordance with the North Dakota Nurse Practice Act. 4. A licensed practical nurse licensed in accordance with the North Dakota Nurse Practice Act and has at least six months of case management experience. 5. A health educator with at least a bachelor’s degree and at least six months of case management experience. 

Supplement 2 to Attachment 3.1-B Page 6 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 6. Licensed Registered Dietitians or Licensed Nutritionists, licensed by the North Dakota Board of Dietetics Practice. 7. If the individual does not have a bachelor’s degree, they will be allowed to enroll to provide TCM if they have at least five years of experience working with high risk pregnant women in a supervised, clinical setting. 8. Individuals enrolled and providing targeted case management prior to July 1, 2020 will be deemed qualified to provide targeted case management, as long as they remain actively providing targeted case management services. Freedom of Choice (42 CFR 441.18(a)(1)): The State assures that the provision of case management services will not restrict an individual’s free choice of providers in violation of section 1902(a)(23) of the Act. 1. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in this plan. 2. Eligible individuals will have free choice of any qualified Medicaid providers of other medical care under the plan. Freedom of Choice Exception (§1915(g)(1) and 42 CFR 441.18(b)): Target group consists of eligible individuals with developmental disabilities or with chronic mental illness. Providers are limited to qualified Medicaid providers of case management services capable of ensuring that individuals with developmental disabilities or with chronic mental illness receive needed services: Access to Services (42 CFR 441.18(a)(2), 42 CFR 441.18(a)(3), 42 CFR 441.18(a)(6)): The State assures the following: x Case management (including targeted case management) services will not be used to restrict an individual’s access to other services under the plan. x Individuals will not be compelled to receive case management services, condition receipt of case management (or targeted case management) services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management (or targeted case management) services; and 

Supplement 2 to Attachment 3.1-B Page 7 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 x Providers of case management services do not exercise the agency’s authority to authorize or deny the provision of other services under the plan. For plans that provide case management services to assist individuals who reside in medical institutions to transition to the community, the State makes the following assurances: x The State assures that the amount, duration, and scope of the case management activities would be documented in an individual's plan of care which includes case management activities prior to and post-discharge, to facilitate a successful transition to the community. x The State assures that case management is only provided by and reimbursed to community case management providers. x The State assures that Federal Financial Participation is only available to community providers and will not be claimed on behalf of an individual until discharge from the medical institution and enrollment in community services. Payment (42 CFR 441.18(a)(4)): Payment for case management or targeted case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. Case Records (42 CFR 441.18(a)(7)): Providers maintain case records that document for all individuals receiving case management as follows: (i)The name of the individual; (ii) The dates of the case management services; (iii)The name of the provider agency and the person providing the case management service; (iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; (v) Whether the individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan. Limitations: Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §441.169 when the case management activities are an integral and inseparable component of another covered Medicaid service (State Medicaid Manual (SMM) 4302.F). 

Supplement 2 to Attachment 3.1-B Page 8 State Plan under Title XIX of the Social Security Act State/Territory: North Dakota TARGETED CASE MANAGEMENT SERVICES FOR PREGNANT WOMEN AND INFANTS TN No. 20-0023 Supersedes Approval Date___________ Effective Date_07-01-2020_ TN No 08-006 Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §441.169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c)) FFP only is available for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that is included in an individualized education program or individualized family service plan consistent with §1903(c) of the Act. (§§1902(a)(25) and 1905(c)) 

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: 20-0024 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th Street, Suite 355 Kansas City, MO 64106

Medicaid & CHIP Operations Group

September 28, 2020

Caprice Knapp, Medicaid Director Division of Medical Services North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250

RE: North Dakota State Plan Amendment (SPA) 20-0024

Dear Ms. Knapp:

We have reviewed the State Plan Amendment (SPA) submitted under transmittal number 20- 0024. This SPA amends the State Plan to remove page T1 from the State Plan which allowed North Dakota to conduct presumptive eligibility for the month of January 2014.

Please be informed that this SPA was approved on September 2, 2020, with an effective date of July 1, 2020. Enclosed is the CMS-179.

Should you have any questions about this amendment, please contact Curtis Volesky at (303) 844-7033.

Sincerely, James Scott, Director Division of Program Operations

Enclosure

cc: Krista Fremming, krfremming@nd.gov Stacey Koehly, skoehly@nd.gov

igitally signed by James G. cott -S ate: 2020.09.28 20:39:36 -05'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO. 0938-0193 FORM CMS-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 1. TRANSMITTAL NUMBER: 20-0024 2. STATE North Dakota 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE July 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: 42 CFR 435.1102 and 1103 7. FEDERAL BUDGET IMPACT: a. FFY 2020 $ 0 b. FFY 2021 $ 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Proposing page be removed from State Plan. 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): T1 10. SUBJECT OF AMENDMENT: Amends the State Plan to remove page T1 from the State Plan which allowed ND to conduct presumptive eligibility for the month of January 2014. 11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED Caprice Knapp, Director, NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL Medical Services Division 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Caprice Knapp, Director Medical Services Division ND Department of Human Services 600 East Boulevard Avenue Dept 325 Bismarck ND 58505-0250 13. TYPED NAME: Caprice Knapp 14. TITLE: Director, Medical Services Division 15. DATE SUBMITTED: August 31, 2020 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: $XJXVW        6HSWHPEHU -XO\ -DPHV*6FRWW      'LUHFWRU'LYLVLRQRI3URJUDP2SHUDWLRQV Digitally signed by James G. Scott -S Date: 2020.09.28 20:40:33 -05'00'

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: 20-0028 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th Street, Suite 355 Kansas City, MO 64106 Medicaid & CHIP Operations Group January 20, 2021 Caprice Knapp, Medicaid Director Division of Medical Services North Dakota Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250 RE: North Dakota State Plan Amendment (SPA) 20-0028 Dear Ms. Knapp: We have reviewed the State Plan Amendment (SPA) submitted under transmittal number 20-0028. This SPA amends the ABP State Plan to add 1915(j) Behavioral Health services. Please be informed that this SPA was approved on January 15, 2021, with an effective date of October 1, 2020. Enclosed is the CMS-179 and SPA pages. Should you have any questions about this amendment, please contact Curtis Volesky at (303) 844-7033. Sincerely, Ruth A. Hughes, Acting Director Division of Program Operations cc: Krista Fremming, krfremming@nd.gov Stacey Koehly, skoehly@nd.gov LeeAnn Thiel, lthiel@nd.gov Stephanie Waloch, swaloch@nd.gov Digitally signed by Ruth A. Hughes Date: 2021.01.20 17:03:57 -06'00'

Medicaid Alternative Benefit Plan: Summary Page (CMS 179) State/Territory name: North Dakota Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. ND-20-0028 Proposed Effective Date 10/01/2020 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(a)(10)(A)(i)(VIII) of the Act and Section 1915(i) of the Social Security Act Federal Budget Impact Federal Fiscal Year Amount First Year 2021 $ 1526400.00 Second Year 2022 $ 1530000.00 Subject of Amendment   Updated North Dakota Medicaid Expansion ABP - Effective October 1, 2020. Pertaining to selection of Secretary-Approved Coverage with source of benefits and any limitation utilized to include a combination Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe:   No reply received within 45 days of submittal Other, as specified Describe:   The Department of Human Services, the Single State Medicaid Agency, is designated to file state plan amendments on behalf of the state Medicaid program. Signature of State Agency Official Submitted By: Krista Fremming Last Revision Date: Nov 5, 2020 Submit Date: Sep 28, 2020 Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 1 of 1 Alternative Benefit Plan Transmittal Number: ND State Name: North Dakota Attachment 3.1-L- OMB Control Number: 0938ဨ1148 - 20 - 0028 Alternative Benefit Plan Populations ABP1 Identify and define the population that will participate in the Alternative Benefit Plan. Alternative Benefit Plan Population Name: North Dakota Medicaid Expansion Identify eligibility groups that are included in the Alternative Benefit Plan's population, and which may contain individuals that meet any targeting criteria used to further define the population. Eligibility Groups Included in the Alternative Benefit Plan Population: Add Eligibility Group: Enrollment is mandatory or voluntary? Remove Add Adult Group Mandatory Remove Enrollment is available for all individuals in these eligibility group(s). Yes Geographic Area The Alternative Benefit Plan population will include individuals from the entire state/territory. Yes Any other information the state/territory wishes to provide about the population (optional) 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.20181119 Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 1 of 3 Alternative Benefit Plan State Name: North Dakota Attachment 3.1-L- OMB Control Number: 0938ဨ1148 Transmittal Number: ND - 20 - 0028 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. No These assurances must be made by the state/territory if the Adult eligibility group is included in the ABP Population. The state/territory shall enroll all participants in the "Individuals at or below 133% FPL Age 19 through 64" (section 1902(a)(10)(A) (i)(VIII)) eligibility group in the Alternative Benefit Plan specified in this state plan amendment, except as follows: A beneficiary in the eligibility group at section 1902(a)(10)(A)(i)(VIII) who is determined to meet one of the exemption criteria at 45 CFR 440.315 will receive a choice of a benefit package that is either an Alternative Benefit Plan that includes Essential Health Benefits and is subject to all 1937 requirements or an Alternative Benefit Plan that is the state/territory’s approved Medicaid state plan not subject to 1937 requirements. The state/territory’s approved Medicaid state plan includes all approved state plan programs based on any state plan authority, and approved 1915(c) waivers, if the state has amended them to include the eligibility group at section 1902(a)(10)(A) (i)(VIII). ✔ The state/territory must have a process in place to identify individuals that meet the exemption criteria and the state/territory must comply with requirements related to providing the option of enrollment in an Alternative Benefit Plan defined using section 1937 requirements, or an Alternative Benefit Plan defined as the state/territory's approved Medicaid state plan that is not subject to section 1937 requirements. ✔ Once an individual is identified, the state/territory assures it will effectively inform the individual of the following: ✔ a) Enrollment in the specified Alternative Benefit Plan is voluntary; b) The individual may disenroll from the Alternative Benefit Plan defined subject to section 1937 requirements at any time and instead receive an Alternative Benefit Plan defined as the approved state/territory Medicaid state plan that is not subject to section 1937 requirements; and c) What the process is for transferring to the state plan-based Alternative Benefit Plan. The state/territory assures it will inform the individual of: ✔ a) The benefits available as Alternative Benefit Plan coverage defined using section 1937 requirements as compared to Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan and not subject to section 1937 requirements; and b) The costs of the different benefit packages and a comparison of how the Alternative Benefit Plan subject to 1937 requirements differs from the Alternative Benefit Plan defined as the approved Medicaid state/territory plan benefits. How will the state/territory inform individuals about their options for enrollment? (Check all that apply) Letter Email Other Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 2 of 3 Alternative Benefit Plan Provide a copy of the letter, email text or other communication text that will be used to inform individuals about their options for enrollment. An attachment is submitted. When did/will the state/territory inform the individuals? The state will notify individuals of their option in the notice received when they are approved as eligible in the new adult group. Please describe the state/territory's process for allowing individuals in the Section 1902(a)(10)(A)(i)(VIII) eligibility group who meet exemption criteria to disenroll from the Alternative Benefit Plan defined using section 1937 requirements and enroll in the Alternative Benefit Plan defined as the state/territory's approved Medicaid state plan. Enrollees will be notified of the ability to seek designation as medically frail. Interested enrollees will complete a questionnaire and submit the questionnaire to the state office. The state's medical staff will review the questionnaire; and if the enrollee meets the minimum thresholds, the enrollee will seek additional documentation from a physician, nurse practitioner, or physician assistant regarding their health status and prescription medication list. The documentation will be submitted to the state office and a final determination will be made regarding the enrollee being designated as medically frail. Once an individual has been designated medically frail, they will be given the option of remaining in the managed care plan or choosing to receive services through the Medicaid State Plan. The state/territory assures it will document in the exempt individual's eligibility file that the individual: ✔ a) Was informed in accordance with this section prior to enrollment; b) Was given ample time to arrive at an informed choice; and c) Chose to enroll in Alternative Benefit Plan coverage subject to section 1937 requirements or defined as the state/territory's approved Medicaid state plan, which is not subject to section 1937 requirements. Where will the information be documented? (Check all that apply) In the eligibility system. In the hard copy of the case record. Other What documentation will be maintained in the eligibility file? (Check all that apply) Copy of correspondence sent to the individual. Signed documentation from the individual consenting to enrollment in the Alternative Benefit Plan. Other The state/territory assures that it will maintain data that tracks the total number of individuals who have voluntarily enrolled in either Alternative Benefit Plan coverage subject to section 1937 requirements or Alternative Benefit Plan coverage defined as the state/ territory's approved Medicaid state plan, which is not subject to section 1937 requirements. ✔ Other information related to benefit package selection assurances for exempt participants (optional): Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 3 of 3 Alternative Benefit 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 Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 1 of 2 Alternative Benefit Plan Transmittal Number: ND State Name: North Dakota Attachment 3.1-L- OMB Control Number: 0938ဨ1148 - 20 - 0028 Enrollment Assurances - Mandatory Participants ABP2c These assurances must be made by the state/territory if enrollment is mandatory for any of the target populations or sub-populations. When mandatorily enrolling eligibility groups in an Alternative Benefit Plan (Benchmark or Benchmark-Equivalent Plan) that could have exempt individuals, prior to enrollment: The state/territory assures it will appropriately identify any individuals in the eligibility groups that are exempt from mandatory enrollment in an Alternative Benefit Plan or individuals who meet the exemption criteria and are given a choice of Alternative Benefit Plan coverage defined using section 1937 requirements or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan, not subject to section 1937 requirements. ✔ How will the state/territory identify these individuals? (Check all that apply) Review of eligibility criteria (e.g., age, disorder/diagnosis/condition) Self-identification Describe: Individuals will use a questionnaire for self-identification if they believe they are medically frail. Enrollees will submit the completed questionnaire to the state. The state's medical services staff will evaluate the questionnaire and if the minimum threshold is met, any supporting documentation from a physician, physician assistant, or nurse practitioner submitted with the questionnaire will be reviewed by a medical professional to validate the diagnoses or medical condition(s) as indicated on the completed questionnaire. If no documentation was submitted with the questionnaire and the minimum threshold was met, the recipient will receive a letter asking them to submit the supporting documentation from a physician, physician assistant, or nurse practitioner. The state’s medical services staff will notify the recipient of the decision. If deemed medically frail, the recipient will have a choice of remaining with the Alternative Benefit Plan or switching to the Medicaid state plan. If enrollee elects to switch to the Medicaid state plan, the status as medically frail may begin no earlier than the first day of the month in which the questionnaire was received by the state. Other The state/territory must inform the individual they are exempt or meet the exemption criteria and the state/territory must comply with all requirements related to voluntary enrollment or, for beneficiaries in the “Individuals at or below 133% FPL Age 19 through 64” eligibility group, optional enrollment in Alternative Benefit Plan coverage defined using section 1937 requirements or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan. ✔ The state/territory assures that for individuals who have become exempt from enrollment in an Alternative Benefit Plan, the state/ territory must inform the individual they are now exempt and the state/territory must comply with all requirements related to voluntary enrollment or, for beneficiaries in the “Individuals at or below 133% FPL Age 19 through 64” eligibility group, optional enrollment in Alternative Benefit Plan coverage defined using section 1937 requirements, or Alternative Benefit Plan coverage defined as the state/territory's approved Medicaid state plan. ✔ How will the state/territory identify if an individual becomes exempt? (Check all that apply) Review of claims data Self-identification Review at the time of eligibility redetermination Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 2 of 2 Alternative Benefit Plan Provider identification Change in eligibility group Other How frequently will the state/territory review the Alternative Benefit Plan population to determine if individuals are exempt from mandatory enrollment or meet the exemption criteria? Monthly Quarterly Annually Ad hoc basis Other Describe: The state is using self-identification as the primary method for identifying if an individual is exempt from mandatory enrollment or meet the exemption criteria. At re-enrollment, the renewal notice will provide notification to the enrollees about the option to seek designation as medically frail. In cases where the self-identification is questionable, the state may review claims data to make a final determination. The state/territory assures that it will promptly process all requests made by exempt individuals for disenrollment from the Alternative Benefit Plan and has in place a process that ensures exempt individuals have access to all standard state/territory plan services or, for beneficiaries in the “Individuals at or below 133% FPL Age 19 through 64” eligibility group, optional enrollment in Alternative Benefit Plan coverage defined using section 1937 requirements, or Alternative Benefit Plan coverage defined as the state/ territory's approved Medicaid state plan. ✔ Describe the process for processing requests made by exempt individuals to be disenrolled from the Alternative Benefit Plan: The eligibility record for individuals deemed medically frail, who choose to disenroll from the Alternative Benefit Plan, will be updated to ensure that managed care premiums are not paid and to ensure that claims can process, fee-for-service, through the state's Medicaid Management Information System. Other Information Related to Enrollment Assurance for Mandatory Participants (optional): 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 Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 1 of 2 Alternative Benefit Plan Transmittal Number: ND State Name: North Dakota Attachment 3.1-L- OMB Control Number: 0938ဨ1148 - 20 - 0028 Selection of Benchmark Benefit Package or Benchmark-Equivalent Benefit Package ABP3.1 Select one of the following: The state/territory is amending one existing benefit package for the population defined in Section 1. The state/territory is creating a single new benefit package for the population defined in Section 1. Name of benefit package: Medicaid Expansion ABP Selection of EHB-Benchmark Plan The state/territory must select an EHB-benchmark plan as the basis for providing Essential Health Benefits in its Benchmark or Benchmark-Equivalent Package. EHB-benchmark plan name: Sanford Health Plan HMO The EHB-benchmark plan is the same as the Section 1937 Coverage option: Yes Assurances 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): 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): A commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state/territory (Commercial HMO): Secretary-Approved Coverage. The state/territory offers benefits based on the approved state plan. 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. Please briefly identify the benefits, the source of benefits and any limitations: The source of benefits and any limitations utilized include a combination of the North Dakota EHB-Benchmark Plan and the approved North Dakota Medicaid State Plan. Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 2 of 2 Alternative Benefit Plan Other Information Related to Selection of the Section 1937 Coverage Option and the EHB-Benchmark Plan (optional): The ABP includes and aligns with the following as approved within the North Dakota Medicaid State Plan: - EHB Prescriptions Drugs effective 01-01-2020 (refer to ABP 5 Benefit Description #6); and - 1915(i) Services effective 10-01-2020 (refer to ABP 5 Benefit Description #14). PRA Disclosure Statement Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) for the purpose of standardizing data. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to 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.20190813 Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 1 of 1 Alternative Benefit Plan Transmittal Number: ND State Name: North Dakota Attachment 3.1-L- OMB Control Number: 0938ဨ1148 - 20 - 0028 Alternative Benefit Plan Cost-Sharing ABP4 Any cost sharing described in Attachment 4.18-A applies to the Alternative Benefit Plan. ✔ Attachment 4.18-A may be revised to include cost sharing for ABP services that are not otherwise described in the state plan. Any such cost sharing must comply with Section 1916 of the Social Security Act. The Alternative Benefit Plan for individuals with income over 100% FPL includes cost-sharing other than that described in Attachment 4.18-A. No Other Information Related to Cost Sharing Requirements (optional): 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 Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 1 of 35 Alternative Benefit Plan State Name: North Dakota Attachment 3.1-L- OMB Control Number: 0938ဨ1148 Transmittal Number: ND - 20 - 0028 Benefits Description ABP5 The state/territory proposes a “Benchmark-Equivalent” benefit package. No Benefits Included in Alternative Benefit Plan Enter the specific name of the base benchmark plan selected: Sanford Health Plan HMO. Enter the specific name of the section 1937 coverage option selected, if other than Secretary-Approved. Otherwise, enter “Secretary-Approved.” Secretary-Approved Coverage with benefits and limitations source from a combination of the North Dakota's EHB Benchmark Plan and the North Dakota Medicaid State Plan. Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 2 of 35 Alternative Benefit Plan 1. Essential Health Benefit: Ambulatory patient services ■ Collapse All Benefit Provided: Outpatient Hospital Surgical Center Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Exclusions include: surgical procedures that can be done in Practitioner's office (i.e. vasectomy, toe nail removal), blood and blood derivatives replaced by the member, and take-home drugs. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Continued exclusions: Panniculectomy or sequela (i.e. anemia, breast reduction, hernia repair, gallbladder removal) as result of gastric bypass surgery; cosmetic services and/or supplies to repair or reshape a body structure primarily for the improvement of a Member’s appearance or psychological well-being or self- esteem, including but not limited to, breast augmentation, treatment of gynecomastia and any related reduction services, skin disorders, rhinoplasty, liposuction, scar revisions, cosmetic dental services; removal of skin tags; and complications from a non-covered procedure or service. Benefit Provided: Primary Care to Treat Illness/Injury Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Exclusions include: Education Programs or Tutoring Services (not specifically defined elsewhere) including, but not limited to, education on self-care or home management; and complications from a non- covered procedure or service. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Specialist Visits Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 3 of 35 Alternative Benefit Plan Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Chiropractic (Therapeutic/Adjustive/Manipulative) Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: 20 Visits per Calendar Year Duration Limit: None Scope Limit: Exclusion include: vitamins except for folic acid and prenatal vitamins for women per plan guidelines, minerals, therabands, cervical pillows, traction services and hot/cold pack therapy including polar ice therapy and water circulating devices. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Chemotherapy Services Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Radiation Therapy Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 4 of 35 Alternative Benefit Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Anesthesia by Local Infiltration Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Walk-in Center Services Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Home Health Care-Non Rehab Source: Base Benchmark Commercial HMO Remove Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 5 of 35 Alternative Benefit Plan Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: 40 Visits per Calendar Year Duration Limit: None Scope Limit: Exclusions include: nursing care requested by, or for the convenience of the patient or the patient's family (rest cures), custodial or convalescent care. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Member must be home-bound to receive home health services. The following is covered if approved by the Plan in lie of Hospital or Skilled Nursing Facility: part-time or intermittent care by a RN or LPN/LVN; part-time or intermittent home health aide services for direct patient care only; physical, occupational, speech, inhalation, and intravenous therapies up to maximum benefit allowable; and/or medical supplies, prescribed medicines, and lab services, to the extent they would be covered if the Member were Hospitalized. One(1) home health visit constitutes four (4) hours of nursing care. Benefit Provided: Access to Clinical Trials Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covered as routine patient costs when provided as part of an Approved Clinical Trial if services are otherwise Covered Service. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Approve Clinical Trial means a phase I, II, III, or IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is one of the following: - federally funded or approved trial; - clinical trail conducted under FDA investigational new drug application; or - drug trial that is exempt from the requirement of an FDA investigational new drug application. Not covered: extra costs related to taking part in Approved Clinical Trial (i.e. additional test which are not part of the member's routine care) or research costs related to conducting the Approved Clinical Trial (i.e. research provider time, analysis of results, and clinical tests performed only for research purposes. Benefit Provided: Dental Injury Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 6 of 35 Alternative Benefit Plan Amount Limit: None Duration Limit: Must be received within 6 months of occurence Scope Limit: Exclusions include: routine dental care and treatment; natural teeth replacements including crowns, bridges, braces or implants; Ossenointegrated implant surgery (dental implants); extraction of wisdom teeth; hospitalization for extraction of teeth; Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Continued exclusions: dental x-rays or dental appliances; shortening of the mandible or maxillae for cosmetic purposes; services and supplies related to ridge augmentation, implantology, and preventative vestibuloplasty; dental appliances of any sort, including but not limited to bridges, braces, and retainers (except for appliances for treatment of TMJ/TMD). Benefit Provided: Oral and Maxillofacial Surgery Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: Must be received within 6 months of occurance Scope Limit: Procedures limited to services required because of injury, accident or cancer that damages natural teeth. Associated radiology services are included. Covered services include those provided in Hospital or dental office. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Diagnosis and treatment of Temporomandibular Joint (TMJ) dysfunction and/or Temporomandibular Disorder (TMD). TMJ splints are covered if the primary diagnosis is TMJ/TMD. Not covered: Routine dental care and treatment; natural teeth replacements including crowns, bridges, braces or implants; osseointergrated implant surgery; extraction of wisdom teeth; hospitalization for extraction of teeth except for NDCC 26.1-36-09.9; dental x-rays and dental appliances; shortening of the mandible for cosmetic purposes; services and supplies related to ridge augmentation, implantology; and preventative vestivuloplasty; dental appliances of any sort. Benefit Provided: Dialysis Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Covered until the enrollee qualifies for the federally funded dialysis services under ESRD. Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 7 of 35 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Services include equipment, training, and medical supplies required for effective dialysis care. Add Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 8 of 35 Alternative Benefit Plan 2. Essential Health Benefit: Emergency services ■ Collapse All Benefit Provided: Emergency Room - Facility Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Not covered: emergency care provided outside the service area if need for care could have been foreseen before leaving the service area; medical or hospital costs resulting from a normal full-term delivery of a baby outside of the service area. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Ambulance Transportation Services Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Coverage is to the nearest provider equipped to furnish the necessary health care services. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Not covered: Transfers performed only for the convenience of the enrollee or the enrollee's family; the enrollee's practitioner and/or provider; services and/or travel expenses relating to a non-emergency medical condition; and complications from a non-covered procedure or service. Benefit Provided: Emergency Room - Professional Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 9 of 35 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Add Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 10 of 35 Alternative Benefit Plan 3. Essential Health Benefit: Hospitalization ■ Collapse All Benefit Provided: Inpatient Medical and Surgical care Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Exclusion include: take home drugs; personal comfort items, private nursing care, costs associated with private rooms, admissions to hospitals performed only for the convenience of the enrollee, the enrollee's family or the enrollee's Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Continued exclusions: practitioner/provider,custodial care, rest cures, services to assist in the activities of daily living. Panniculectomy or sequela (i.e. anemia, breast reduction, hernia repair, gallbladder removal) as result of gastric bypass surgery; cosmetic services and/or supplies to repair or reshape a body structure primarily for the improvement of a Member’s appearance or psychological well-being or self-esteem, including but not limited to, breast augmentation, treatment of gynecomastia and any related reduction services, skin disorders, rhinoplasty, liposuction, scar revisions, cosmetic dental services; removal of skin tags; and complications from a non-covered procedure or service. Benefit Provided: Bariatric Surgery Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: Once per Lifetime Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Organ and Tissue Transplants Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 11 of 35 Alternative Benefit Plan Scope Limit: Covers transplants that meet the United Network for Organ Sharing (UNOS) criteria and/or Plan policy requirements and are performed at Plan Participating Providers or contracted Centers of Excellence. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Coverage is provided for transplants according to the Plan’s medical coverage guidelines (available upon request) for the following services: pre-operative care; transplant procedure, facility, and professional fees; organ acquisition costs; bone marrow or stem cell acquisition and short term storage therapy for a member’s with a covered illness; short-term storage of umbilical cord blood for a member with a malignancy undergoing treatment when there is a donor match; post-transplant care and treatment; drugs (including immunosuppressive drugs); supplies; psychological testing; and living donor transplant-related complications for sixty (60) days following the date the organ is removed, if not otherwise covered by donor’s own health benefit plan, by another group health plan, or other coverage arrangements. Not covered: transplant evaluations with no end organ complications; storage of stem cells including storing umbilical cord blood of non-diseased persons for possible future use; artificial organs, any transplant or transplant services not listed above; expenses incurred by a member as a donor, unless the recipient is also a member; costs related to locating organ donors; donor expenses for complications that occur after sixty (60) days from the date the organ is removed, when the donor is not covered as a member under this Plan; services, chemotherapy, radiation therapy (or any therapy that damaged the bone marrow), supplies drugs and aftercare for or related to artificial or non-human organ transplants; services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not specifically approved by the Plan’s Chief Medical Officer or its designee; services, chemotherapy, supplies, drugs and aftercare for or related to transplants performed at a non-Plan Participating center of excellence facilities; and transplants and transplant evaluations that do not meet the United Network for Organ Sharing (UNOS) criteria. Benefit Provided: Anesthesia Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Services of an anesthesiologist or other certified anesthesia provider in conjunction with a certified inpatient or outpatient procedure or treatment. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Hospice Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 12 of 35 Alternative Benefit Plan Amount Limit: None Duration Limit: None Scope Limit: Exclusions include: independent nursing, homemaker services, respite care. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: The following circumstances apply: (1) the enrollee has been diagnosed with a terminal disease and a life expectancy of six months or less, (2) the enrollee has chosen a palliative treatment focus; and (3) the enrollee continues to meet the terminally ill prognosis. The following Hospice Services are Covered Services: a. Admission to a hospice Facility, Hospital, or skilled nursing Facility for room and board, supplies and services for pain management and other acute/chronic symptom management b. In-home hospice care per Plan guidelines (available upon request) c. Part-time or intermittent nursing care by a RN, LPN/LVN, or home health aid for patient care up to eight (8) hours per day d. Social services under the direction of a Participating Provider e. Psychological and dietary counseling f. Physical or occupational therapy, as described under Section 3(a) g. Consultation and Case Management services by a Participating Provider h. Medical supplies, DME and drugs prescribed by a Participating Provider i. Expenses for Participating Providers for consultant or Case Management services, or for physical or occupational therapists, who are not Group Members of the hospice, to the extent of available coverage for these services, but only where the hospice retains responsibility for the care of the Member. Benefit Provided: Blood Transfusions Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Pheresis Therapy is a covered service. Benefit Provided: Breast Reduction Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 13 of 35 Alternative Benefit Plan Amount Limit: None Duration Limit: None Scope Limit: Not covered as a result of gastric bypass surgery. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Reconstructive Surgery Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Surgery to restore bodily function or correct a deformity caused by illness or injury; mastectomy; and related benefits. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Not covered: surgical placement of non-covered prosthetics; panniculectomy or sequela (i.e. anemia, breast reduction, hernia repair, gallbladder removal) as result of gastric bypass surgery that do not meet medical necessity; cosmetic surgeries, services and/or supplies to repair or reshape a body structure primarily for the improvement of a Member’s appearance or psychological well-being or self-esteem and not medically necessary, including but not limited to, breast augmentation, treatment of gynecomastia and any related reduction services, skin disorders, rhinoplasty, liposuction, scar revisions, or cosmetic dental services; removal of skin tags, prophylactic (preventive) surgeries (i.e. mastectomy, oopherectomy); and removal, revision, or re-implementation of saline or silicone implants that do not meet medical necessity criteria. Benefit Provided: Inhalation Therapy Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 14 of 35 Alternative Benefit Plan Add Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 15 of 35 Alternative Benefit Plan 4. Essential Health Benefit: Maternity and newborn care ■ Collapse All Benefit Provided: Delivery and Maternity Services Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: Up to 4 Ultrasounds per Pregnancy Duration Limit: None Scope Limit: Covers prenatal through postnatal maternity care and delivery and care for complications of pregnancy of the mother. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: The minimum inpatient stay, when complications are not present, ranges from 48 hours for a vaginal delivery to a minimum of 96 hours for a cesarean birth, excluding the day of delivery. Such inpatient stays may be shortened if the treating practitioner and/or provider, after consulting with the mother, determines that they mother and child meet certain criteria and that discharge is medically appropriate. If such an inpatient stay is shortened, a post-discharge follow-up visit shall be provided to the mother. Benefit Provided: Pre and Postnatal Care Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Includes prenatal through postnatal maternity care and delivery and care for complications of pregnancy of the mother. Up to 4 routine ultrasounds per pregnancy to determine fetal age, size and development are allowed. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Exclusion include: Amniocentesis or chorionic villi sampling (CVS) solely for sex determination. Benefit Provided: Infertility Services Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: Limited to Plan Guidelines Duration Limit: None Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 16 of 35 Alternative Benefit Plan Scope Limit: Includes testing for the diagnosis of infertility. Limited to the Plan Guidelines which are available upon request. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Not covered: treatment of infertility including artificial means of conception such as artificial insemination, in-vetro fertilization, ovum/embryo placement or transfer, or gamete intra-fallopian tube transfer;cryogenic or other preservation techniques used in such or similar procedures; infertility medication; any other service or supplies related to artificial means of conception; reversals of prior sterilization procedures; and/or any expenses related to surrogate parenting. Add Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 17 of 35 Alternative Benefit Plan 5. Essential Health Benefit: Mental health and substance use disorder services including behavioral health treatment ■ Collapse All The state/territory assures that it does not apply any financial requirement or treatment limitation to mental health or 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: Mental Inpatient Treatment Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: As with other medical/surgical benefits, failure to get prior authorization for inpatient services, including those provided by a hospital or residential treatment facility, may result in a reduction or denial of benefits. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Not covered: convalescent care; marriage, family, bereavement, pastoral, financial, legal, or custodial care counseling; educational or non-medical services related to learning disabilities; services related to environmental change; educational or non-medical services related to behavioral therapy, modification or training; milieu therapy; or sensitivity training. For enrollees ages 21 and older, services rendered in an IMD, room and board at a Residential Treatment Facility and Applied Behavioral Analysis (ABA) services are not covered. Benefit Provided: Substance Use Disorder Inpatient Treatment Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: As with other medical/surgical benefits, failure to get prior authorization for inpatient services, including those provided by a hospital or residential treatment facility, may result in a reduction or denial of benefits. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Not covered: confinement services to hold or confine an enrollee under chemical influence when no Medically Necessary services are provided, regardless of where services are received (e.g. detoxification centers); domiciliary or maintenance care; convalescent or custodial care; marriage, family, bereavement, pastoral, financial, legal, or custodial care counseling; educational or non-medical services related to learning disabilities; services related to environmental change; educational or non-medical services related to behavioral therapy, modification or training; milieu therapy; or sensitivity training. For enrollees ages 21 and older, services rendered in an IMD and room and board at a Residential Treatment Facility are not covered. Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 18 of 35 Alternative Benefit Plan Benefit Provided: Mental Outpatient Treatment Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Coverage includes outpatient professional services, including individual/group therapy by providers such as psychiatrists, psychologists, or clinical social workers; medication management; diagnostic tests, electroconvulsive therapy (ECT); Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: partial hospitalization, and/or intensive outpatient; and telephonic consultation for an enrollee diagnosed with depression and is within 12 weeks of starting anti-depressant therapy. Telephonic consultation coverage limit of 1 per enrollee for depression and 1 per enrollee for Attention Deficit Hyperactive Disorder. Not covered: convalescent care; marriage, family, bereavement, pastoral, financial, legal, or custodial care counseling; educational or non-medical services related to learning disabilities; services related to environmental change; educational or non-medical services related to behavioral therapy, modification or training; milieu therapy; or sensitivity training. For enrollees ages 21 and older, Applied Behavioral Analysis (ABA) services are not covered. Benefit Provided: Substance Abuse Disorder Outpatient Treatment Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Coverage includes alcohol, chemical and gambling treatment; outpatient professional services, including individual/group therapy by providers such as psychiatrists, psychologists, clinical social workers, licensed chemical dependency counselors, or Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: other qualified mental health and substance abuse disorder professionals; partial hospitalization; and intensive outpatient programs. Not covered: confinement services to hold or confine an enrollee under chemical influence when no Medically Necessary services are provided, regardless of where services are received (e.g. detoxification centers); long term care in a mental health facility; convalescent care; marriage, family, bereavement, pastoral, financial, legal, or custodial care counseling; educational or non-medical services related to learning disabilities; services related to environmental change; educational or non-medical services related to behavioral therapy, modification or training; milieu therapy; sensitivity training; convalescent or custodial care; or domiciliary or maintenance care. Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 19 of 35 Alternative Benefit Plan Add Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 20 of 35 Alternative Benefit Plan 6. Essential Health Benefit: Prescription drugs ■ The state/territory assures that the ABP prescription drug benefit plan is the same as under the approved Medicaid State Plan for prescribed drugs. ✔ Benefit Provided: Coverage is at least the greater of one drug in each U.S. Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark. Prescription Drug Limits (Check all that apply.): Limit on days supply Limit on number of prescriptions Limit on brand drugs Other coverage limits Preferred drug list Authorization: Yes Provider Qualifications: State licensed Coverage that exceeds the minimum requirements or other: Prescription drug coverage as described in the North Dakota State Plan Attachment 3.1-A #12a including #12a within the Attachment of Attachment 3.1-A. Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 21 of 35 Alternative Benefit Plan 7. Essential Health Benefit: Rehabilitative and habilitative services and devices ■ Collapse All The state/territory assures that it is not imposing limits on habilitative services and devices that are more stringent than limits on rehabilitative services (45 CFR 156.115(a)(5)(ii)). Further, the state/territory 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. ✔ Benefit Provided: Physical, Speech and Occupational Therapy Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: 30 Visits per Year per Therapy per Service Duration Limit: None Scope Limit: This benefit covers both habilitation and rehabilitation. Limits are not cumulative for both habilitation and rehabilitation services. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Exclusions include: services provided in enrollee's home for convenience, hot/cold pack therapy and water circulating devices; speech therapy for the purpose of correcting speech impediments (stuttering or lisps), or assisting in the initial development of verbal facility or clarity; voice training or voice therapy. Exclusions include: Alternative treatment therapies including, but not limited to: acupuncture, aquatic whirlpool therapy, chelation therapy, massage therapy, naturopathy, homeopathy, holistic medicine, hypnotism, hypnotherapy, hypnotic anesthesia, sleep therapy (except for treatment of obstructive apnea), therapeutic touch, lifestyle improvement services, such as physical fitness programs, or health or weight loss clubs or clinics, educational programs, vocational and job rehabilitation, recreational therapy, traction services, and special education including sign language lessons to instruct a member. Benefit Provided: Cardiac Rehabilitation Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: 30 Days per Calendar Year Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 22 of 35 Alternative Benefit Plan Benefit Provided: Durable Medical Equipment Source: Base Benchmark Commercial HMO Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: Limited to Plan Guidelines Duration Limit: Scope Limit: Prior authorization and/or limitations may apply to certain items per the Plan guidelines (available upon request). Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Not Covered: • Home Traction Units • Orthopedic shoes; custom made orthotics; over-the-counter orthotics and appliances • Disposable supplies (including diapers) or non-durable supplies and appliances, including those associated with equipment determined not to be eligible for coverage • Revision of durable medical equipment, except when made necessary by normal wear or use • Replacement or repair of equipment if items are damaged or destroyed by Member misuse, abuse, or carelessness, lost, or stolen • Duplicate or similar items • Sales tax, mailing, delivery charges, service call charges, or charges for repair estimates • Items which are primarily educational in nature or for vocation, comfort, convenience or recreation • Household equipment which primarily has customary uses other than medical, such as, but not limited to, air purifiers, central or unit air conditioners, water purifiers, non-allergic pillows, mattresses or waterbeds, physical fitness equipment, hot tubs, or whirlpools • Household fixtures including, but not limited to, escalators or elevators, ramps, swimming pools and saunas • Home Modifications including, but not limited to, its wiring, plumbing or changes for installation of equipment • Vehicle modifications including, but not limited to, hand brakes, hydraulic lifts, and car carrier • Remote control devices as optional accessories Benefit Provided: Prosthetics and Orthotics Source: Base Benchmark Commercial HMO Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: Limited to Plan Guidelines Duration Limit: None Scope Limit: Prior authorization and/or limitations may apply to certain items per the Plan guidelines (available upon request). Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Covers prosthetic limbs, sockets and supplies, and prosthetic eyes; externally worn breast prostheses and Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 23 of 35 Alternative Benefit Plan surgical bras including necessary replacements following a mastectomy (single mastectomy includes 2 external prosthesis and 4 bras per Calendar and double mastectomy coverage extends to 4 external prostheses and 4 bras per Calendar Year; and adjustments, modifications, and/or repairs to prosthesis required by wear/tear or due to a change in member’s condition or to improve the function as long as repairs do not exceed the estimated expense of purchasing another prosthesis. Not covered: experimental and/or investigational services or devices except as part of an approved clinical trial; replacement or repair of items (if destroyed by enrollee's misuse, abuse or carelessness, lost or stolen); duplicate or similar items; service call charges, labor charges or charges for repair estimates; wigs, cranial prosthesis, or hair transplants; cleaning and polishing of prosthetic eye; or genital prosthetics, including penile prosthesis and related services. Benefit Provided: Skilled Nursing Facility Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: 30 Days in a Consecutive 12 Month Period Duration Limit: None Scope Limit: Exclusions include: ustodial care, convalescent care, rest cures, services to assist in activities of daily living. Services in lieu of continued or anticipated hospitalization. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Skilled nursing care in a hospital is covered if the level of care needed by the enrollee has been classified from acute care to skilled nursing care and no designated skilled nursing care beds or swing beds are available in the hospital or in another hospital within a 30 mile radius of the hospital. Benefit Provided: Home Health Care-Rehab (PT, OT, Speech Therapy) Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: 40 Visits per Year Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: This benefit covers both habilitation and rehabilitation. Add Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 24 of 35 Alternative Benefit Plan 8. Essential Health Benefit: Laboratory services ■ Collapse All Benefit Provided: Lab Tests, X-ray Services, and Pathology Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Imaging / Diagnostics (MRI, CT Scan, PET Scan) Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: None Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Outpatient Diagnostic Labs, X-Ray and Pathology Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Not covered: Thermograms or Thermology Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 25 of 35 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Add Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 26 of 35 Alternative Benefit Plan 9. Essential Health Benefit: Preventive and wellness services and chronic disease management ■ Collapse All The state/territory must provide, at a minimum, a broad range of preventive services including: “A” and “B” services recommended by the United States Preventive Services Task Force; Advisory 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). Benefit Provided: Colorectal Cancer Screening Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Excludes virtual colonoscopies Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Nutritional Counseling Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Coverage includes foods and low-protein modified food products determined by a physician to be medically necessary for the therapeutic treatment of an inherited metabolic disease of amino acid or organic acid. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Excludes weight loss programs. Not covered: dietary desserts and snack items. For Phenylketonuria (PKU); coverage includes testing, diagnosis, and treatment of PKU including dietary management, formulas, case management, intake and screening, assessment, comprehensive care planning and service referral. Not covered for PKU: dietary desserts and snack items. Benefit Provided: Smoking Cessation Program Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 27 of 35 Alternative Benefit Plan Amount Limit: 2 attempts per year Duration Limit: None Scope Limit: Not covered: hypnotism and acupuncture Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Benefit Provided: Allergy Testing and Injections Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Includes testing and treatment, allergy injections, and allergy serum. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Exclusions include: provocative food testing and sublingual allergy desensitization. Benefit Provided: Family Planning Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Includes consultations and pre-pregnancy planning. The following drugs, services, and devices are covered: barrier methods - diaphragm and cervical cap fitting/purchase; mirena and paragard intrauterine devices only with placement/removal covered Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: once every five (5) years; and/or generic oral contraceptives, other contraceptives including injectable medroxyprogesterone acetate, and emergency contraception with generic Plan B are covered at 100% (no cost). Voluntary sterilizations are covered and include: medical - occlusion of the fallopian tubes by use of permanent implants (e.g. Essure) and/or surgical - tubal ligation or vasectomies. Tubal ligation covered at 100% of allowed only when performed as the primary procedure and if performed as part of a maternity delivery or for any other medical reason it will be covered as a medical benefit with the applicable cost- Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 28 of 35 Alternative Benefit Plan share applied. Not covered: genetic counseling or testing except for services that have a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force - prior authorization required; Reproductive Health Care Services which are prohibited by the laws of North Dakota; and/or reversal of voluntary sterilization. Benefit Provided: Diabetes Equipment and Supplies; Education Source: Base Benchmark Commercial HMO Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Excludes food items for medical nutritional therapy. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Coverage includes: Blood glucose monitors including continuous glucose monitoring systems (this DME requires certification); Blood glucose monitors for the legally blind; Test strips for glucose monitors; Urine testing strips; Insulin injection aids; Lancets and lancet devices; Insulin pumps and all supplies for the pump (this DME requires certification), Custom diabetic shoes and inserts limited to one (1) pair of depth- inlay shoes and three (3) pairs of inserts or one (1) pair of custom molded shoes (including inserts) and three (3) additional pairs of inserts; Syringes; Insulin infusion devices (this DME requires certification; Prescribed oral agents for controlling blood sugars; Glucose agents; Glucagon kits; Insulin measurement and administration aids for the visually impaired and other medical devices for the treatment of diabetes; and Routine foot care including toe nail trimming. Diabetes self management training and education shall be covered if the service is provided by a Physician, nurse, dietitian, pharmacist or other licensed health care Practitioner and/or Provider who satisfies the current academic eligibility requirements of the National Certification Board for Diabetic Educators and has completed a course in diabetes education and training or has been certified by a diabetes educator and; the training and education is based upon a diabetes program recognized by the American Diabetes Association or a diabetes program with a curriculum approved by the American Diabetes Association or the North Dakota Department on Health. Benefit Provided: Foot Care Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Include routine foot care for diabetes; non-routine diagnostic testing and treatment of the foot due to illness or injury. Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 29 of 35 Alternative Benefit Plan Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Exclusions include: cutting, removal, or treatment of corns, calluses, or nails for reasons other than authorized corrective surgery; diagnosis and treatment of weak, strained, or flat feet. Benefit Provided: Preventive Services Source: Base Benchmark Commercial HMO Remove Authorization: None Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Exclusions include: sports physicals, pre-employment and employment physicals, insurance physicals, or government licensing physicals (including, but not limited to physicals and eye exams for driver's licenses). Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: The following preventive services, as defined in the Affordable Care Act, received from an in-network provider are covered at no charge: evidenced based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force; immunizations for routine use that have in effect a recommendations from the Advisory Committee on Immunization Practices of the Centers of Disease Control and Prevention with respect to the Member involved; with respect to covered persons who are age 19 and 20 - evidence informed preventative care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration and EPSDT; and with respect to covered persons who are women, such additional preventive care and screening not described above are provided for in comprehensive guidelines supported by the Health Resources and Services Administration. Add Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 30 of 35 Alternative Benefit Plan 10. Essential Health Benefit: Pediatric services including oral and vision care ■ Collapse All Benefit Provided: Medicaid State Plan EPSDT Benefits Source: Base Benchmark Commercial HMO Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: None Duration Limit: None Scope Limit: Services noted as not covered in all other benefit areas must be provided when medically necessary for enrollees under 21 years of age. Some services may require prior authorization. Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: Add Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 31 of 35 Alternative Benefit Plan 11. Other Covered Benefits from Base Benchmark Collapse All Other Base Benefit Provided: Vision Services Source: Base Benchmark Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: Other Duration Limit: None Scope Limit: Other information regarding this benefit: Includes: Non-routine vision exams relating to eye disease or injury to the eye; eyeglasses/contacts lenses with diagnosis of aphakia; eyeglasses, including one frame per lifetime up to $200 or clear contact lenses for the aphakia eye for 2 single lenses per CY; and scleral Shells with soft shells limited to 2 per calendar year and hard shells limited to 1 per lifetime. Not covered: Routine vision exams, refractive errors of the eye; purchase, examinations, or fitting of eyeglasses or contact lenses; radial keratotomy, myopic keratomileusis, and any surgery involving corneal tissue for the purpose of altering, modifying, or correcting myopia, hyperopia, or stigmatic error; replacement of lost, stolen, broken, or damaged lenses or glasses, bifocal contact lenses, special lens coating or lens treatment for prosthetic eyewear; glasses and/or contacts after cataract surgery; routine cleaning of scleral shells. Add Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 32 of 35 Alternative Benefit Plan 12. Base Benchmark Benefits Not Covered due to Substitution or Duplication Collapse All Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 33 of 35 Alternative Benefit Plan 13. Other Base Benchmark Benefits Not Covered Collapse All Base Benchmark Benefit not Included in the Alternative Benefit Plan: Newborn Coverage Source: Base Benchmark Remove Explain why the state/territory chose not to include this benefit: Newborn Coverage will be provided under the newborn's eligibility under the traditional Medicaid program. Base Benchmark Benefit not Included in the Alternative Benefit Plan: Residential Treatment Room and Board Coverage Source: Base Benchmark Remove Explain why the state/territory chose not to include this benefit: For those members 21 and older, coverage at a Residential Treatment Facility does not include room and board. Add Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 34 of 35 Alternative Benefit Plan 14. Other 1937 Covered Benefits that are not Essential Health Benefits Collapse All Other 1937 Benefit Provided: 1915(i) Behavioral Health HCBS Source: Section 1937 Coverage Option Benchmark Benefit Package Remove Authorization: Other Provider Qualifications: Medicaid State Plan Amount Limit: Other Duration Limit: Other Scope Limit: Other Other: Effective Date 10/01/2020. For those members meeting the eligibility criteria in relation to the 1915(i) Behavioral Health HCBS as specified within Attachment 3.1(i) of the approved North Dakota Medicaid State Plan, Alternative Benefit Plan coverage includes the services along with the various limits and time frames in the extensive service details of the components of the 1915(i) as specified in Attachment 3.1(i) of the North Dakota Medicaid State Plan. Other 1937 Benefit Provided: Abortion Services Source: Section 1937 Coverage Option Benchmark Benefit Package Remove Authorization: Prior Authorization Provider Qualifications: Medicaid State Plan Amount Limit: Other Duration Limit: Other Scope Limit: Coverage may not be extended and payment may not be made for any abortion services greater than the Hyde Amendment. Other: Coverage/payment for abortion services as described in the North Dakota State Plan #5a within the Attachments of Attachment 3.1-A and 3.1-B. Add Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 35 of 35 Alternative Benefit Plan 15. Additional Covered Benefits (This category of benefits is not applicable to the adult group under section 1902(a)(10)(A)(i)(VIII) of the Act.) Collapse All PRA Disclosure Statement Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) for the purpose of standardizing data. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to 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.20190808 Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 1 of 2 Alternative Benefit Plan Transmittal Number: ND State Name: North Dakota Attachment 3.1-L- OMB Control Number: 0938ဨ1148 - 20 - 0028 Benefits Assurances ABP7 EPSDT Assurances If the target population includes persons under 21, please complete the following assurances regarding EPSDT. Otherwise, skip to the Prescription Drug Coverage Assurances below. The alternative benefit plan includes beneficiaries under 21 years of age. Yes The state/territory assures that the notice to an individual includes a description of the method for ensuring access to EPSDT services (42 CFR 440.345). ✔ The state/territory assures EPSDT services will be provided to individuals under 21 years of age who are covered under the state/ territory 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/territory will provide additional benefits to ensure EPSDT services: Through an Alternative Benefit Plan. Through an Alternative Benefit Plan with additional benefits to ensure EPSDT services as defined in 1905(r). Other Information regarding how ESPDT benefits will be provided to participants under 21 years of age (optional): Prescription Drug Coverage Assurances The state/territory assures that it meets the minimum requirements for prescription drug coverage in section 1937 of the Act and implementing regulations at 42 CFR 440.347. Coverage is at least the greater of one drug in each United States Pharmacopeia (USP) category and class or the same number of prescription drugs in each category and class as the base benchmark. ✔ The state/territory assures that procedures are in place to allow a beneficiary to request and gain access to clinically appropriate prescription drugs when not covered. ✔ The state/territory assures that when it pays for outpatient prescription drugs 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 permitted under section 1937 of the Act. ✔ The state/territory assures that when conducting prior authorization of prescription drugs under an Alternative Benefit Plan, it complies with prior authorization program requirements in section 1927(d)(5) of the Act. ✔ Other Benefit Assurances The state/territory assures that substituted benefits are actuarially equivalent to the benefits they replaced from the base benchmark plan, and that the state/territory has actuarial certification for substituted benefits available for CMS inspection if requested by CMS. ✔ The state/territory 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 1905(a)(2) of the Social Security Act. ✔ Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 2 of 2 Alternative Benefit Plan The state/territory assures that payment for RHC and FQHC services is made in accordance with the requirements of section 1902(bb) of the Social Security Act. ✔ The state/territory assures that it will comply with the requirement of section 1937(b)(5) of the Act by providing, effective January 1, 2014, to all Alternative Benefit Plan participants at least Essential Health Benefits as described in section 1302(b) of the Patient Protection and Affordable Care Act. ✔ The state/territory assures that it will comply with the mental health and substance use disorder parity requirements of section 1937(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. ✔ The state/territory assures that it will comply with section 1937(b)(7) of the Act by ensuring that benefits provided to Alternative Benefit Plan participants include, for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section. ✔ The state/territory assures transportation (emergency and non-emergency) for individuals enrolled in an Alternative Benefit Plan in accordance with 42 CFR 431.53. ✔ The state/territory assures, in accordance with 45 CFR 156.115(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; Advisory 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 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 Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 1 of 4 Alternative Benefit Plan State Name: North Dakota Attachment 3.1-L- OMB Control Number: 0938ဨ1148 Transmittal Number: ND - 20 - 0028 Service Delivery Systems ABP8 Provide detail on the type of delivery system(s) the state/territory 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 delivery system(s) the state/territory will use for this Alternative Benefit Plan(s). Select one or more service delivery systems: Managed care. Managed Care Organizations (MCO). Prepaid Inpatient Health Plans (PIHP). Prepaid Ambulatory Health Plans (PAHP). Primary Care Case Management (PCCM). Fee-for-service. Other service delivery system. Managed Care Options Managed Care Assurance The state/territory 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 Part 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 efforts. The Department of Human Services has conducted outreach through: providing testimony to various legislative committees, presenting to provider and advocacy groups, presenting to county social service board and commissioners, developing a dedicated web page, meeting with tribal health and Indian Health Services representatives, and developing public service announcements. MCO: Managed Care Organization The managed care delivery system is the same as an already approved managed care program. Yes The managed care program is operating under (select one): Section 1915(a) voluntary managed care program. Section 1915(b) managed care waiver. Section 1932(a) mandatory managed care state plan amendment. Section 1115 demonstration. Section 1937 Alternative (Benchmark) Benefit Plan state plan amendment. Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 2 of 4 Alternative Benefit Plan Identify the date the managed care program was approved by CMS: December 20, 2013 Describe program below: The State has chosen Secretary-Approved Coverage offering an array of benefits through the combination of the North Dakota EHB-Benchmark Plan and the approved North Dakota Medicaid State Plan. In addition, Alternative Benefit Plan incorporates the Essential Health Benefits and ensures compliance with Mental Health and Substance Abuse parity. This group enrolled in the MCO will be solely limited to those individuals eligible in the new adult group under the Medicaid expansion. Medicaid Expansion beneficiaries, including American Indians, will be mandatorily enrolled in one managed care plan offered statewide. The Medicaid Expansion will include individuals who meet the qualifications of the exempt populations as outlined in Section 1937(a)(2)of the Act. Individuals who meet the qualifications of the exempt population can choose to receive the ABP that is the Medicaid State Plan benefit or the ABP that includes Essential Health Benefits. The Medicaid State Plan benefit will be provided through a fee-for-service delivery system. The Alternative Benefit Plan will be provided through a managed care delivery system as outlined in the approved section 1915(b) waiver. The Alternative Benefit Plan will be provided through primary care case management (PCCM) consistent with applicable managed care requirements (42 CFR Part 438, section 1903(m) of the Social Security Act, and section 1932 of the Social Security Act). ✔ MCO Procurement or Selection Method Indicate the method used to select MCOs: Competitive procurement method (RFP, RFA). Other procurement/selection method. Describe the method used by the state/territory to procure or select the MCOs: Other MCO-Based Service Delivery System Characteristics One or more of the Alternative Benefit Plan benefits or services will be provided apart from the managed care organization. Yes List the benefits or services that will be provided apart from the MCO, and explain how they will be provided. Add as many rows as needed. Add Benefit/service Description of how the benefit/service will be provided Remove Add Pharmacy Benefits-Services Outpatient Pharmacy Benefit-Services submitted as medical claims shall be through the Managed Care Delivery System as administered and managed by the MCO; however, Outpatient Pharmacy Benefit- Services submitted as pharmacy claims shall be through the Fee-For-Service Delivery System as administered and managed by the Department. Remove MCO service delivery is provided on less than a statewide basis. No MCO Participation Exclusions Individuals are excluded from MCO participation in the Alternative Benefit Plan: Yes Select all that apply: Individuals with other medical insurance. Individuals eligible for less than three months. Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 3 of 4 Alternative Benefit Plan Individuals in a retroactive period of Medicaid eligibility. Other: General MCO Participation Requirements Indicate if participation in the managed care is mandatory or voluntary: Mandatory participation. Voluntary participation. Indicate the method for effectuating enrollment: Describe method of enrollment in MCOs: Medicaid Expansion beneficiaries, including American Indians, will be mandatorily enrolled in the one managed care plan offered statewide. The Medicaid Expansion will include individuals who meet the qualifications of the exempt populations as outlined in Section 1937(a)(2)of the Act. Individuals who meet the qualifications of the exempt population can choose to receive the ABP that is the Medicaid State Plan benefit or the ABP that includes Essential Health Benefits. The Medicaid State Plan benefit will be provided through a fee-for-service delivery system. Additional Information: MCO (Optional) Provide any additional details regarding this service delivery system (optional): Fee-For-Service Options Indicate whether the state/territory offers traditional fee-for-service and/or services managed under an administrative services organization: Traditional state-managed fee-for-service Services managed under an administrative services organization (ASO) arrangement Please describe this fee-for-service delivery system, including any bundled payment arrangements, pay for performance, fee-for- service care management models/non-risk, contractual incentives as well as the population served via this delivery system. For those individuals determined medically frail who elect ABP that is the Medicaid State Plan benefit; for those individuals who are incarcerated who receive only qualifying inpatient care; and for those non-citizen individuals who receive treatment for an emergency medical condition as required under 42 CFR §435.139; and for those individuals who have Hospital Presumptive Eligibility until a full determination can be made. Additional Information: Fee-For-Service (Optional) Provide any additional details regarding this service delivery system (optional): As noted under the Other MCO-Based Service Delivery System Characteristics section above - Outpatient Pharmacy Benefit-Services submitted as medical claims shall be through the Managed Care Delivery System as administered and managed by the MCO; however, Outpatient Pharmacy Benefit-Services submitted as pharmacy claims shall be through the Fee-For-Service Delivery System as administered and managed by the Department Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 4 of 4 Alternative Benefit 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.20181119 Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 1 of 1 Alternative Benefit Plan Transmittal Number: ND State Name: North Dakota Attachment 3.1-L- OMB Control Number: 0938ဨ1148 - 20 - 0028 Employer Sponsored Insurance and Payment of Premiums ABP9 The state/territory provides the Alternative Benefit Plan through the payment of employer sponsored insurance for participants with such coverage, with additional benefits and services provided through a Benchmark or Benchmark-Equivalent Benefit Package. No The state/territory otherwise provides for payment of premiums. No Other Information Regarding Employer Sponsored Insurance or Payment of Premiums: 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 Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 1 of 1 Alternative Benefit Plan Transmittal Number: ND State Name: North Dakota Attachment 3.1-L- OMB Control Number: 0938ဨ1148 - 20 - 0028 General Assurances ABP10 Economy and Efficiency of Plans The state/territory assures that Alternative Benefit Plan coverage is provided in accordance with Federal upper payment limit requirements and other economy and efficiency principles that would otherwise be applicable to the services or delivery 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. No Please describe your approach below: The premiums paid will more closely reflect commercial insurance rates, adjusted for managed care savings, acuity and other applicable adjustments. Medicaid rate setting does not typically consider cost shifting, acuity and other adjustments. Compliance with the Law The state/territory will continue to comply with all other provisions of the Social Security Act in the administration of the state/ territory plan under this title. ✔ The state/territory assures that Alternative Benefit Plan benefits designs shall conform to the non-discrimination requirements at 42 CFR 430.2 and 42 CFR 440.347(e). ✔ The state/territory assures that all providers of Alternative 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 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 Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Page 1 of 1 Alternative Benefit Plan Transmittal Number: ND State Name: North Dakota Attachment 3.1-L- OMB Control Number: 0938ဨ1148 - 20 - 0028 Payment Methodology ABP11 Alternative Benefit Plans - Payment Methodologies The state/territory provides assurance that, for each benefit provided under an Alternative Benefit Plan that is not provided through managed care, it will use the payment methodology in its approved state plan or hereby submits state plan amendment Attachment 4.19a, 4.19b or 4.19d, as appropriate, describing the payment methodology for the benefit. ✔ An attachment is submitted. 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 Transmittal Number: ND 20-0028 Supersedes: ND 20-0004 Approval Date: January 15, 2021 Effective Date: October 1, 2020

Table of Contents State/Territory Name: North Dakota State Plan Amendment (SPA) #: 22-0022 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group October , 2022 Caprice Knapp, Director Medical Services Division ND Department of Human Services 600 East Boulevard Avenue Dept. 325 Bismarck, ND 58505-0250 Re: North Dakota State Plan Amendment (SPA) 22-0022 Dear Ms. Knapp: The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) ND-22-0022. This amendment proposes to amend the State Plan to change state plan page Attachment 2.6-A Page 26 to reflect that the state uses the maximum Community Spouse Resource standard permissible under federal law. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations 1924 of the Act. This letter is to inform you that North Dakota Medicaid SPA 22-0022 was approved on October 3, 2022, with an effective date of October 1, 2022. If you have any questions, please contact Tyson Christensen at (816) 426-6440 or via email at tyson.christensen@cms.hhs.gov. Sincerely, James G. Scott, Director Division of Program Operations cc: LeeAnn Thiel

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. STATE 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a. FFY $ b. FFY $ 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGENUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) 9. SUBJECT OF AMENDMENT 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 11. SIGNATURE OF STATE AGENCY OFFICIAL 15. RETURN TO 12. TYPED NAME 13. TITLE 14. DATE SUBMITTED FOR CMS USE ONLY 16. DATE RECEIVED 17. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 19. SIGN AL 20. TYPED NAME OF APPROVING OFFICIAL 21. TITLE OF APPROVING OFFICIAL 22. REMARKS FORM CMS-179 (09/24) Instructions on Back

TN No. 22-0022 Approval Date __________ Effective Date 10-1-2022 Supersedes TN No. 07-003 Revision: HCFA-PM-99-1 Attachment 2.6-A Page 26a OMB No.: 0938-0673 State: North Dakota Citation Condition of Requirement The agency does not count the funds in a trust in any instance where the agency determines that the transfer would work an undue hardship, as described in Supplement 10 to Attachment 2.6-A. 1924 of the Act 15. The agency complies with the provisions of §1924 with respect to income and resource eligibility and post-eligibility determinations for individuals who are expected to be institutionalized for at least 30 consecutive days and who have a spouse living in the community. When applying the formula used to determine the amount of resources in initial eligibility determinations, the State standard for community spouses is: The maximum standard permitted by law; The minimum standard permitted by law; or A standard that is an amount between minimum and the maximum. 1917(f) of the Act 16. The agency complies with the provisions of §1917(f) with respect to coverage of long-term care services for individuals with excess home equity as identified in Supplement 17 to Attachment 2.6-A.

Table of Contents State/Territory Name: ND State Plan Amendment (SPA) #: 22-0026 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages



  

 

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The SPA revises the PACE rate development methodology to align with current state processes and federal requirements, and to relocate the Post-Eligibility Treatment of Income (PET!) election pages within the state plan using the updated preprint, without updating the election language.

Approval Document

This SPA amends the State Plan to update reimbursement methodologies for prescribed drugs.

Approval Document

This plan amendment proposes to amend the State Plan to implement a two percent inflationary increase for Psychiatric Residential Treatment Facility Services.

Approval Document

This amendment amends the Alternative Benefit State Plan to add licensed master social workers as Other Licensed Practitioner in Medicaid Expansion for 19–20-year-olds.

Approval Document

This amendment amends the Alternative Benefit State Plan to add licensed master social workers as Other Licensed Practitioner in Medicaid Expansion for 21–64-year-olds.

Approval Document

This plan amendment proposes to amend the State Plan to update the resident classification requirements and to implement an inflationary increase for Nursing Facility Services.

Approval Document

This plan amendment proposes to amend the State Plan to reimburse therapeutic leave days for Psychiatric Residential Treatment Facilities.

Approval Document

This amendment amends the State Plan to update service definitions and update practitioners to various services.

Approval Document

This amendment amends the State Plan to add Licensed Practical Nurses to provide Nursing Services provided in a school.

Approval Document

This amendment amends the State Plan to add licensed master social workers as Other Licensed Practitioner.

Approval Document

This amendment will amend the State Plan to update the designee for State Plan submissions.

Approval Document

This amendment amends the Alternative Benefit State Plan to include coverage for Community Health Worker and Community Paramedic Services.

Approval Document

This amendment revises the state plan to incorporate the updated template for these pages and remove the end date for coverage of Medication Assisted Treatment Services in accordance with the Consolidated Appropriations Act (CAA) of 2024.

Approval Document

This amendment provide coverage for Community Paramedic and Emergency Medical Technician services.

Approval Document

This amendment provides coverage for Community Health Worker services.

Approval Document

This SPA implements a technical correction to align the effective date of the 1915(i) payment pages with the rest of the 1915(i) renewal plan pages.

Approval Document

This plan amendment amends the State Plan to reimburse a Long-Acting Reversible Contraceptive Device outside of a DRG payment.

Approval Document

This plan amendment proposes a rate increase for home health services.

Approval Document

This plan amendment proposes a two percent rate increase for services rendered by Medicaid Providers.

Approval Document

This plan amendment proposes a rate increase for 1915i services.

Approval Document

This plan amendment implements an inflationary increase of two percent for Intermediate Care Facilities.

Approval Document

This amendment the provides coverage for clinic services provided outside the four walls of the clinic.

Approval Document

This amendment makes changes to the North Dakota Medicaid Expansion Alternative Benefits Plan (ABP) to align with the 19-20-year-old ABP. This SPA is a technical change to add to the Other Licensed Providers section.

Approval Document

The purpose of this amendment is to renew North Dakota’s 1915(i) State Plan HCBS benefit.

Approval Document

This amendment increases the personal needs allowance.

Approval Document

This amendment aligns the Alternative Benefit Plans (ABP) for 19-20-year-olds Medicaid expansion members.

Approval Document

This amendment extends to the exemption for a Recovery Audit Contractor.

Approval Document

Clarifies language for existing benefits, specifically as they relate to those under the age of 21. The amendment will align the Alternative Benefits Plan (ABP) with the changes to traditional Medicaid.

Approval Document

This amendment updates the recipient and provider qualifications for Target Case Management (TCM) for individuals with a behavioral health condition.

Approval Document

This plan amendment amends the State Plan to reimburse hospital leave days for Psychiatric Residential Treatment Facilities.

Approval Document

This plan amendment updates the inflation factor for Psychiatric Residential Treatment Facilities (PRTF) daily rates.

Approval Document

This plan amendment authorizes a three percent (3.0%) inflationary increase for all Nursing Facility services.

Approval Document

This plan amendment updates the distribution methodology for the nursing facility incentive program.

Approval Document

This State Plan Amendment updates state plan assurances in accordance with federally mandated quality reporting requirements for the Child Core Set and the behavioral health quality measures on the Adult Core Set outlined in 42 CFR 431.16 and 437.10 through 437.15

Approval Document

This amendment is to update the plan to broaden coverage of nursing services in schools by removing the requirement that nursing services be listed in an to Individualized Education Program (IEP), as well as amend the tobacco cessation counseling services to include that these services must be provided by a licensed practitioner.

Approval Document

This amendment adds school psychologists as an Other Licensed Practitioner.

Approval Document

This amendment will combine skills restoration with skills integration and add additional practitioners to various services.

Approval Document

This plan amendment provides for a two percent inflationary increase for Intermediate Care Facility (ICFs) services.

Approval Document

This plan amendment provides for inflationary increases for certain inpatient hospital service payments.

Approval Document

This amendment, the state updated the Conflict of Interest (COI) standards section of the SPA to comport with regulatory requirements and expanded the target group criteria to include individuals with any behavioral health condition, substance abuse disorder or brain injury.

Approval Document

This plan amendment proposes to implement an increase of three percent for services rendered by Medicaid Providers for various non-institutional services.

Approval Document

This plan amendment proposes to reimburse other licensed practitioners at 100% of the Medicaid fee schedule and implement an increase of three percent for services rendered by Medicaid Providers.

Approval Document

This plan amendment proposes an increase of three percent for Rural Health Clinic Services.

Approval Document

This plan amendment proposes an increase of three percent for 1915(i) Services.

Approval Document

This Amendment increases the income standard for its Optional Targeted Low-Income Children eligibility group.

Approval Document

Effective for dates of services on or after January 1, 2024, this amendment implements a nursing facility (NF) incentive program for instate nursing facilities.

Approval Document

This SPA updates the state’s non-alignment alternative benefit plan (ABP) for Medicaid expansion individuals ages 21-64 to remove the WHODAS assessment scores from the 1915(i) language.

Approval Document

This SPA updates the state’s non-alignment alternative benefit plan (ABP) for Medicaid expansion individuals ages 19-20 to remove the WHODAS assessment scores from the 1915(i) language and to remove the PCCM service delivery model.

Approval Document

Amends the State Plan to increase the number of therapeutic leave days for nursing facilities.

Approval Document

Amends the State Plan to implement rate increases for Nursing Facility Services.

Approval Document

Amends the State Plan to implement a three percent inflationary increase for Psychiatric Residential Treatment Facility Services.

Approval Document

Amends the State Plan to implement a value-based purchasing program for in-state PPS hospitals.

Approval Document

This State Plan identifies the single state agency as the North Dakota Department of Health and Human Services.

Approval Document

This Amendment changes to the income disregards and financial methodologies applied to certain medically needy groups.

Approval Document

This amendment amends the State Plan to add coverage of adult vaccines and to update vaccines rates quarterly.

Approval Document

This SPA amends the State Plan to add coverage of select weight loss medications.

Approval Document

With this amendment the state is making the following updates: remove annual service limits and revise provider qualifications for care coordination, benefits planning, housing supports, revocational training, supported employment, and supported education.

Approval Document

in which the state increases the income eligibility level for pregnant women and provide coverage to lawfully residing pregnant women.

Approval Document

This state plan amendment will supersede SPA ND-23-0020 and updates reimbursement for in-state PPS outpatient hospital services to the Enhanced Ambulatory Patient Group (EAPG) payment system.

Approval Document

This amendment will end the Primary Care Case Management program.

Approval Document

This amendment aligns the Alternative Benefit Plan for 19- 20-Year-Old Medicaid Expansion Members.

Approval Document

The Amendment updates the Designee for State Plan submissions.

Approval Document

This SPA, removes the Medication Therapy Management (MTM) specific section to avoid duplicated language within this section.

Approval Document

Amends the State Plan to update the supplement payment for Critical Access Hospitals.

Approval Document

Amends the State Plan to implement an increase of three percent for certain Inpatient Hospital Services.

Approval Document

Amends the State Plan to implement an inflationary increase of two percent and wage increase for ICF Services.

Approval Document

This amendment amends the State Plan to update provider qualifications for Targeted Case Management (TCM) for individuals with Serious Mental Illness (SMI) or Serious Emotional Disturbance (SED).

Approval Document

This amendment amends the State Plan to increase the personal needs allowance.

Approval Document

This State Plan Amendment implements an increase of 3% for vaccine administration under the Pediatric Immunization program.

Approval Document

Amends the State Plan to implement an increase of three percent for EPSDT Services.

Approval Document

This state plan amendment implements a 3% inflationary increase for North Dakota Medicaid Providers providing 1915i services.

Approval Document